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IMMIGRANT WOMEN, WORK AND HEALTH

Christina M. Bancej

A Thesis Submitted to the School of Graduate Studies and Research in Partial Fulfilment of the Requirements for a

Master of Science Oegree

Joint Departments of Epidemiology, Biostatistics and Occupational Health McGill University Montreal, Quebec

August, 1997

8 Chrisüna Bancej, 1997

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ABSTRACT

This stud y examines the association between immigrant women's self-reported

health and their employrnent status and occupation using data on 859 immigrant

women aged 20-64 from the 1994-95 National Population Health Survey. Of this group,

502 were in paid employment, 107 assessed their global health as poor, and 158

reported one or more disability days in the previous two weeks. Distress scores ranged

from 0-21 (rnean 3.85). Logistic and multiple linear regression showed being employed

(vs. not being in paid empioyment) was associated with better self-assessed global

health when age, education, income, marital status, country of birth and time since

immigration were controlled and women's care-giving role was accounted for.

However, this protective association was weaker in women who also reported caring for

their family as a main activity. Significant associations between work and disability

days or mental distress did not occur. Among 476 immigrant women currently

employed in their main occupation, manual workers had poorer self-reported health and

higher mental distress scores than others.

RÉSUME

Cette Btude analyse l'association entre I'auto-évaluation de santé des

immigrantes et leur situation professionnelle et leur emploi, en utilisant des données

tirdes de l'Enquête nationale sur la santé de la population 1994-95 concernant 859

immigrantes entre les âges de 20 et 64 ans. Parmi ce groupe, 502 ont des emplois

rémunérés, 107 ont décrit leur santé générale comme pauvre ou passable, et 158 ont

d6claré au moins un jour d'incapacitk dans les deux semaines précédentes. Les côtes

de détresse psychologique étaient entre O et 21 (une moyenne de 3.85). La régression

logistique, et multilinéaire ont montré que le fait d'avoir un emploi (contre le fait d'être

sans emploi rémunéré) était associee a une meilleure auto-évaluation de I'état de santé

quand l'âge, l'éducation, le revenu, I'6tat civil, le pays de naissance, et le temps depuis

l'immigration &aient contrôl&s, et le soin de la famille &ait prise en compte.

Cependant, cette association protectrice faiblit chez les femmes qui aussi prennent soin

de la famille comme leur activité principale. On ne trouve pas d'associations

significatives entre le travail et les jours d'incapacitb ou la détresse psychologique.

Parmi les 476 femmes immigrantes employées B leur travail principal, l'auto-évaluation

de l'état de santé des travailleuses manuelles était plus mauvaise, et leur niveau de

détresse psychologique &ait plus M v é que les autres.

ACKNOWLEDGMENTS

I would like to thank my supervisor, Dr. Abby Lippman for her extraordinary

amount of guidance, editing, suggestions and support for this project, and Dr. Jim

Hanley for his helpful cornments and suggestions for the statistical analyses. Than ks

also to Kitty Wilkins at Statistics Canada for her help in obtaining the data, and for her

resources and the time she spent to help me understand the survey. Finally, thank you

to NSERC for the financial support given to me while I was conducting this research.

... 111

TABLE OF CONTENTS

ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i

ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

LIST OF TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

LIST OF APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

INTRODUCTION TO THESIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

LITERATURE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2.1 INTRODUCTION TO LITERATURE REVIEW . . . . . . . . . . . . . . . . . . . . 3

............................... 2.2 WOMEN. WORK AND HEALTH 4

Associations Between Employment Status and Health . . . . . . . . . . . . . . 4

Associations Between Occupation and Health . . . . . . . . . . . . . . . . . . . . 7

Women's Other Social Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Combining Social Roles With Structural Position ................. 13

............................... Different Dimensions of Health 14

2.3 LIMITATIONS OF THE LITERATURE ......................... 15

............................. The Problem of Health Selection 15

Problerns With Employment Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Problems With Occupation 17

Lack of Attention to the Context of Women's Lives . . . . . . . . . . . . . . . . 20

2.4 IMMIGRANT WOMEN. WORK. AND HEALTH . . . . . . . . . . . . . . . . . . . 21

The Health of Immigrant Women ............................. 22

Immigrant Women . Employment Status and Health . . . . . . . . . . . . . . . 23

Immigrant Women. Occupation. and Health . . . . . . . . . . . . . . . . . . . . . 25

Combining Domestic and Paid Work in Immigrant Women ......... 29

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ethnicity and Immigrant Health 31

. . . . . . . . . . . . . . . . . . . . . . . . . 2.5 LIMITATIONS OF THE LITERATURE 33

Complexity of Immigrant Population . . . . . . . . . . . . . . . . . . . . . . 33

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Immigrant Status 33

CultureIEthnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

LengthofStay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Healthy Immigrant Effect 37

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Assessrnent of Health 38

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Measuring Occupation 40

Data Quality ........................................ 40

2.6 SUMMARY AND OBJECTIVES OF DATA ANALYSE . . . . . . . . . . . . . 42

METHODS ................................................... 44

........................ 3.1 STUDY DESIGN AND DATA SOURCE 44

3.2 SAMPLING IN THE NPHS AND THE USE OF WEIGHTS . . . . . . . . . . . . 44

3.3 METHODS OF DATA COLLECTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4 MlSSlNG DATA 47

3.5 STUDY POPULATION FORTHESIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

3.6 DESCRIPTION OF VARIABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Main Independent Variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Ernployment Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

......................................... Occupation 49

Fotential Confounders or Effect Modifiers ....................... 49

Age ........................................... 49

Socioeconomic Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . 49

Social Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ethnicity 51

Time Since Immigration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Health Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

DerivedVariables . . ....................................... 52

Work Status Variable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Caregiving Variable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

DependentVanables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

3.7 STATISTICALMETHODS ................................... 56

4 RESULTS OF ANALYSIS OF WORK STATUS-HEALTH ASSOCIATION . . . 58

4.1 DESCRIPTION OF STUDY POPULATION . . . . . . . . . . . . . . . . . . . . . . 58

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2 PRELIMINARYANALYSES 59

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bivariate Associations 59

Association Between Work Status. Potential Confounders and . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health 59

. . . . . . . Association of Potential Confounders with Work Status 61

Covariates Meeting 60th Criteria for Confounding . . . . . . . . . . . 62

Tri- and Multivariate Analyses- Effect Modifiers of Work-Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Associations 64

. . . . . 4.3 MULTIPLE LINEAR AND MULTIPLE LOGISTIC REGRESSION 65

Self-Assessed Heafth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Disability Days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Mental Distress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

RESULTS OF SUB-ANALYSIS OF ASSOCIATION BETWEEN MANUAL

OCCUPATION AND HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

. . . . . . . . . . . . . . . . . . . . . . 5.1 DESCRIPTION OF STUDY POPULATION 70

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2 PRELIMINARYANALYSES 71

Bivariate Associations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Association Between Occupation. Potential Confou nders and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

. . . . . . . Association of Potential Confounders with Occupation 72

P otential Confounders Meeting Both Criteria for Confounding Variable ........................................... 72

Stratified Analysis: Confounders of the Occupation-Health Association .................................................. 72

vii

..... 5.3 MULTIPLE LINEAR AND MULTIPLE LOGISTIC REGRESSION 74

Self-Assessed Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Disability Days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Mental Distress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

5.4 FINAL MODELS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

COMPARISON OF RESPONDENTS REMOVED FROM STUDY DUE TO . . . . . . . . . MlSSlNG INFORMATION WlTH THOSE REMAlNlNG IN STUDY 76

DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

7.1 MAIN FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

7.2 SECONDARY FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

7.3 LIMITATIONS OF STUDY AND SUGGESTIONS FOR FUTURE

RESEARCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

Study Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

Conceptual Difficulties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

Validity Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

7.4 STRENGTHS OF STUDY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . APPENDICES 120

LIST OF TABLES

TABLE 1:

TABLE 2:

TABLE 3:

TABLE 4:

TABLE 5:

TABLE 6:

TABLE 7:

TABLE 8a:

TABLE 8b:

TABLE 9:

TABLE IO:

TABLE 11:

TABLE 12:

TABLE 13:

TABLE 14:

TABLE 15:

Description of Study Population of 859 Immigrant Women of Working Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . * * . . . . . * * 77

Proportion of Subjects with Poor Self-Assessed Health, One or More Disability Day, and Mean Distress Score by Work Status or Level of Potential Confounders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Distribution of Potential Confounders Arnong Categories of Work Status . . . . . . . . . . . . . . . . . . . . . . . . . * . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Association of Potential Confounders with Work Status and Health . . 81

Measures of Association with Health from Simple Linear and Simple Logistic Regressions for Work Status and Potential Confounders . . . . 82

Strength of Work Status-Health Association Upon Control of Potential Confounders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Effect Modification by Caregiver Status . . . . . . . . . . . . . . . . . . . . . . . 85

Final Model for Work-Self-Assessed Health Association . . . . . . . . . . . 87

Odds Ratios and 95% Confidence Intervals for Association Between Work and Self-Assessed Health by Caregiver Status . . . . . . . . . . . . . . . . . . 87

Final Model for Work-Disability Days Association . . . . . . . . . . . . . . . . . 88

Final Model for Work-Mental Distress Association . . . . . . . . . . . . . . . . 88

Characteristics of Study Population of Women Currently Working in Main Job(N476) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Association of Potential Confounders with Manual Occupation . . . . . . 90

Association of Manual Occupation and Potential Confounders with HeallRi

Measures of Association with Health from Simple Linear and Simple Logistic Regressions for Occupation and Potential Confounders . . . . . 92

Association Between Health Outcome and Working in Manual Occupation Upon Control of Potential Confounders . . . . . . . . . . . . . . . . . . . . . . . . 94

a TABLE 1 6: Results of Automated Selection Procedures for Mental Distress, Disability Days and Self-Assessed Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

TABLE 17: Final Models for SeFAssessed Health, Disability Days and Mental Distress in Immigrant Women Currently Working in Main Occupation . 96

TABLE 18: Comparison of Respondents Removed Due to Missing information with those Retained in Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

0 APPENDIX 1:

APPENDIX 2:

APPENDIX 3:

APPENDIX 4:

APPENDIX 5:

APPENDIX 6:

APPENDlX 7:

APPENDIX 8:

LIST OF APPENDICES

Final Models Using Weights ........................... 120

Interview Questions in NPHS Relevant to Study . . . . . . . . . . . 123

. . . . . . Coding of Original NPHS Variables Relevant to Study 131

. . . . . . . . Criteria Used by NPHS to Derive lncome Adequacy 135

. . . . . . Grouping of Collapsed NPHS Variables Used in Study 136

Derivation of Work Status Variable . . . . . . . . . . . . . . . . . . . . . 137

Model Selection for Association between Work and Health in Immigrant Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138

Conceptual Model of Association Between Work Status. Occupational Status and Health State . . . . . . . . . . . . . . . . . . . 146

a 1 INTRODUCTION TO THESIS

Since the mid 1980's, annual levels of immigration to Canada have risen.

Between 1986 and 1991, Canada's immigrant population increased by 1 1 % [16]. About

half of al1 new immigrants are female, entering largely as dependents in the family class

[721*

The health status of female immigrants differs from that of immigrant men and

native-bom women. Although several factors have been examined in association with

immigrant wornen's health, little focus has been applied to examining their work status

and labour force position in association with their health. It should be noted that in this

thesis, employed refers to women in the paid labour force, unemployed refers to women

who are actively seeking employment, and non-employed refers to women who are not

in the paid labour force who are not actively seeking employment '. The literature on the socioeconornic positioning of immigrant women shows

many apparent inconsistencies. When evaluated as a whole, immigrant women have

average incomes comparable to Canadian-bom women. Nevertheless, a

d isproportionate number are among the most socioeconomically d isadvantaged grou ps

within Canadian society and more immigrant women have incomes below the Statistics

Canada low incorne cutoff than do the Canadian-bom. Similarly, immigrant women are

more likely to be employed overall, yet unemployment rates are higher for immigrant

women in al1 age groups. Finally, despite being about equally likely to be employed as

professionals or managers as Canadian-bom women, larger numbers of immigrant

women are found at the lowest positions in the occupational hierarchy [72].

1. ln some studies a broad definifion of non-employment is used which includes the unernployed (e.g.[14]).

0 What these apparent paradoxes demonstrate is that immigrant women are a

heterogenous group, and examining averages often conceals this variability.

Immigrant women are bimodally distributed across income and occupational

hierarchies. They are more likely to be working or actively seeking employment, while

less likely to be non-employed (not in paid employment by choice), which explains how

they can have both higher rates of employment and unemployment.

The greater number of immigrant wornen in the lower echelons of the woMorce

is largely attributable to the higher proportion of immigrant women working in product

fabricating occupations. These occupations have been called "ethnic linguistic job

ghettos" and have been characterized as having many negative attributes such as low

wages, poor working conditions and high job insecurity (61). Concerns about the health

consequences of working in such low status occupations are found throughout the

literature. However, a detailed quantitative description of the associations between

work status, occupation and health in immigrant women is lacking.

2 LITERATURE REVIEW

2.1 INTRODUCTION TO LITERATURE REVIEW

No previous analysis has quantitatively evaluated the associations between

immigrant women's health and their labour force activities, while sirnultaneously

considering women's additional roles and controlling for confounders. This study will

focus on associations between immigrant women's work status, occupation and il1

health to identify immigrant women in the labour force who are at special risk for

different dimensions of poor health as measured by self-assessed health, days of

restricted activity in the previous two weeks, and mental distress. Using data collected

from 91 1 immigrant women between the ages of 20 and 64 in the National Population

Health Survey by Statistics Canada, the cornplex associations between work and health

in women identified as born outside Canada will be explored.

Given this aim, this selected literature review begins with a broad overview of the

literature provided by other population suweys on the associations behrveen work and

health in women in general, and then sumrnarizes what is known specifically about the

health of immigrant women. Three issues are highlighted: how their health differs from

that of immigrant men and native-bom women, how their work and health are related,

and how their status as immigrants may affect their health. It should be noted that while

a growing body of literature exists examining the health effects of wornen's specific

biological and physical occupational exposures, such information was not available for

use in this thesis. Here, the emphasis will be on the social roles and structural positions

related to an immigrant woman's working and living conditions, that may be associated

with health. Throughout this literature review, problems and limitations will be

hig hlig hted.

0 2.2 WOMEN, WORK AND HEALTH

Researchers examining the associations between employment status,

occupation and health have corne to acknowledge that findings based on men cannot

simply be generalized to women. Women. unlike many men, have more than one

dominant social role, and the centrality of occupation in the lives of men cannot be

immediately assumed to hold the same position in the Ives of women. Others have

recognized that the working conditions of men and women cannot be considered equal,

especially insofar as wamen are occupationally segregated, perforrn different tasks than

men, are more often victims of discrimination and harassment. and are, on average,

paid less [53, 651. Women also more comrnonly have the additional responsibility of

unwaged domestic labour [go]. Thus, simply adjusting for sex when examining work

and health is inadequate since the standard indicators used do not reflect these

differences.

Associations Between Employment Status and Health

Most simple analyses of associations between work and health have shown that

paid work is beneficial to wornen. More cornprehensive studies, however, have

produced contradictory findings- evidence that these associations cannot be so simply

represented. Indeed, ernployment may lead to health or illness, as can unemployment

and non-employment, depending on many factors, including what type of job is lost or

gained, for what reasons and the social and matenal contexts in which paid and unpaid

work is done. In the following section, consistencies in the associations between work

and health in women will be discussed, followed by a discussion of the inconsistencies

and complexities that become evident once work is considered in the wntext of

women's lives.

a Work outside the home has been seen as potentially beneiicial to the health of

women in several ways: it can elevate self-esteern, provide social support, allow

initiative, judgement and decision-making skills to be exercised and be a source of

satisfaction as well as income [65]. Paid employment has been said to be one of the

most important deteminants of health status in women, with employed wornen

reporting better health than those who are unpaid homemakers [il, 801. The better

health of employed women has been reported irrespective of material circumstances,

marital and parental status, and in many domains of health [11,49]. Thus, although

much research on women's health in relation to paid work has focused on mental

illness, other indicators such as self-assessed global health, chronic illness, days of

restricted activity, depression, limited-longstanding illness, and psychological symptoms

have also been used [il ,14,49]. In studies examining associations between work

status and several different dimensions of health, apparent consistencies have led

some reviewers to state that research uniformly shows better physical health among

employed than non-em ployed women [65]. In support of this assertion, ernployment

status has been associated primarily with subjective health, and somewhat less strongly

with limiting long-standing illness [49]. Macran et al., using four different masures of

health, found that women not involved in paid work, even if they reported no disabilities,

had poorer scores than the employed for al1 masures used. although for illness

symptoms, a non-significant difference was noted [49]. Cross-sectional data from the

Canadian Health Promotion Survey found that being involved in paid work was

associated with better self-assessed health and fewer activity limitations; however, in

some instances, women who had better health (employed women, women with

children) were also the most likely to report high levels of stress [80].

The reported associations between employment status and mental health

measures have also shown uniforrnities, with some authors reporting that even the

most routine work appears to protect women against depression [80] and to have

positive effects on various rneasures of mental distress [19]. Research from Britain

found that non-employed women reported a high rate of affective disorders and young

unemployed women reported an even higher level than any other work status group

[57. Some research has shown that the unemployed are particularly affected in their

psycho-social health, reporting poorer health, even when physical measures such as

fitness, illness, and disease/disability were not distinguishable from those found in the

employed [49]. Similady. full-tirne work was more strongly associated with a lower level

of syrnptoms of malaise as compared with physical symptoms.

Because many studies examining associations between employment status and

health have used data obtained from cross-sectional surveys, there has been concem

by some authors that these associations merely refiect selection processes that

disqualiw or inhibit less healthy individuals from entering employment or remaining

employed [8,49, 501. Some research has attempted to crudely alleviate the problems

of health selection by restricting analyses to people who report themselves to be free of

any illness, injury or disability that restricts their acüvities, and studies of this type have

yielded varying results. Some have found that even when controlling for health

selection, women who were not in paid work were still more likely to assess their health

poorly [19,49, 501, making it unlikely that the poor health of the non-employed is

entirely explained by differential selection of women with poor health out of paid work.

By contrast, Arber et al. [14] found little evidence that employment benefitted women of

al1 ages with children after excluding those who reported a chronic illness. Employment

was only associated with better health in younger women without children.

Longitudinal data have supported the idea that changes in employment status

result in changes in health, rather than the converse [33]. For instance, Graetz et al.

found that employed people who lost their jobs showed a significant deterioration in

their psychological health, while unemployed people who found work showed a

significant improvement. However, these changes do not resuit in a similar change in

the overall psychiatrk case rate [33]. In sum then, the data suggest a general effect on

physical health of paid work and non-ernployment, and an even stronger effect on

mental health, but seiection biases are pooriy controlled, and even more problematic,

there is an absence of detail on employment status beyond the paidlunpaid dichotomy

or on confounding factors.

Empl~yment status is, in itself, a measure which is lacking in detail. It is

important to note that an individual's employment status per se says nothing about the

hours of work, whether exposure to the job is full-time or part-time, what conditions and

hazards are present in the work place, or what other activities need to be juggled along

with the role of paid worker [80]. Besides employment status itself, transitions into and

out of paid work [8], involvement in other social roles such as mother [19], the nature of

the employment and specific health risks of the job (531, and job satisfaction [33, 651 are

al1 components that play important roles in the relationships between work and

women's health, and need to be addressed if we are to understand differences among

employed women.

Associations Between Occupation and Health

Complementing the research which examines the problems and benefits

associated with paid work per se, are studies that also look at occupation in conjunction

0 with employment status. These aim for a more accurate representation of the role of a

person's position in the labour market with respect to health [IO, 1 11. In these studies,

health consequences of worû have been shown to depend on the quality of work

obtained, with those entering unsatisfying work showing no health benefits [33]. Not

surprisingly, time pressures, high demands, low levels of control, excessively close

supervision, and highly repetitive work have al1 been associated with poorer health [65].

One approach to examining health in relation to differences in type of work

considers the sector of the economy in which wornen work. Specific occupations rnay

have certain health risks or benefits associated with them because of specific

occupational hazards [50], conditions of work, workload [19], as well as behavior,

attitudes, and social networks associated with occupational social class 119, 501.

Occupational class may be associated with health status both through the direct effects

of working conditions [il, 501 and through the influence on the material circumstances

of an individual and her family [ I l ] . For example. studies have shown occupation to be

a more important factor than either household income, employrnent status or household

type in the self-assessed health of women 1501, although others have shown income to

be more strongly related when examining affective disorders and minor physical

morbidity [12]. As well, previous employment in higher status occupations continues to

be associated with better health, even years after retirement and in the non- and

unemployed [1 O].

Many measures of health have been associated with employment status and

occupation. Current activities can trigger acute illness or daily symptoms in an

individual's state of health, while the different activities perfonned over a lifetime

contribute ta chronic conditions and mortality (651. Variations in absence from work

a have been said to be potentially useful in identifying hazardous working conditions,

although they are not precise indicators [53].

Recent British studies have shown that women in certain occupational groups

experience disproportionately high morbidity and mortality. For example, studies using

Standardized Mortality Ratios (SMRs) found excessively high ratios in low occupational

classes. When Potential Years of Life Lost (PYLL) is used as a measure of relative

mortality, an even greater difference between the lowest and highest occupational

classes is apparent refiecting the higher incidence of earîy deaths in manual workers

[W. These differences are reflected in morbidity as well, even when the analysis

controls for income, suggesting that occupational groups measure something other

than merely the advantage associated with higher income. Although overall, women

who are in paid work experience better health than women who are not, there is also

great variation according to what a woman does for pay. Factory workers have attracted

the interest of some researchers (531, with cross-sectional data indicating that women in

factory or unskilled occupations expenence high levels of psychological strain with

many working in unhealthy environments [49]. Similariy, wornen in rnanual occupations

report poor health more often than those in non-manual jobs [14]. For example, the

prevalence of limiting longstanding illness was almost three times higher in women in

unskilled jobs cbmpared with professional women [12]. Similarly, professionall

managerial women are less likely to experience physical symptoms than women

working in clencal positions, while women in manual occupations have a higher risk

thân clerical workers [tg]. Data from the Framingharn study grouped women into

manual, cledcal and white collar occupations and found that clerical workers were at

0 significantly higher risk of developing heart disease, particularly mamed wornen, or

those with children [35].

As with employrnent status, there are also complexities in interpreting

associations between occupation and health. The varying associations found by

different studies rnay be due, in part. to how occupation is defined and what dimension

of health is used. For example. the gradient in health does not exactly follow the

gradient of occupational class [72,49]. Nonetheless, the data do make clear that there

are differences in health according to the sector of the labour force in which a woman

works. There is a clear manuallnon-manual division in health, with non-manual workers

having advantaged health. Sales workers are an exception to this dichotomy, as it has

been shown that they share more commonalities in their health with rnanual workers,

although they are usually classed as non-manual [49]. Associations with health may

also differ according to which dimension of health is measured. For example, teachers

have been found to have unusually good psycho-social health, while other professional

women have shown poor psycho-social health. but high fitness levels [49, 501.

Women's Other Social Roles

Several studies have recognized that women occupy varying roles, for example,

those of wife, rnother and paid worker, and these activities may interact to contribute

differently to a woman's health. Despite more women being in paid employment, their

domestic and childcare responsibilities are not diminishing. Even when women are

employed, responsibility for looking after their homes and farnilies is assumed by them.

For employed women with a spouse and at least one child under the age of five years,

household labour and childcare amount to a second full-time job, and women spend

twice as much time on such activities as their male counterparts [l, 801. Caring

responsibilities are not limited to childcare. It has been reported that half of Canadian

women who are now between 35 and 64 will care for an elderly relative at some point in

tirne [80].

Family responsibilities may interrupt careers, force women into part-time

employment, or force them to accept work that does not reflect their skill level or

education simply because it fits in with their other responsibilities [50]. Wives are often

expected to support their partner's career, both directly and indirectly, often at the

expense of their own [65]. For women, unlike for men, parental and marital status

interact with paid employment to produce different effects on health [il].

Some have hypothesized that although balancing multiple roles can require

innovative managing, it is still a benefit, or at least not a detriment, to health [65]. A job

may buffer negative aspects of other roles, conferring advantages such as new sources

of self-esteem, increased social contact and emotional support, sense of worth, an

alternative source of gratification, and increased financial independence [Il, 14, 651.

Supporting this role enhancement hypothesis are data that show that those with fewer

additional roles, such as socially isolated widowed, divorced or separated women, were

seen to benefit more from paid employment than those who already had additional

roles, such as mothers [14,65].

However, health benefits do not extend indefinitely with added roles, and

multiple roles can cause strain. For example, regardless of whether they had

dependent children or not, part-time work was more advantageous than full-time work

for women over forty. Adding the multiple activities of being a mother and wife to the

demands of the work environment results in additional stress, fatigue and conflict,

particularly when household labour is unequally divided [il, 12, 14,651. Mothers under

the age of forty working full-time experience poorer health than both those without

children, or those with children who work part-tirne or not at al1 [Ml. Single mothers

report exceptionall y poor health, regardless of employment status [65], but among

single mothers, those in full-time employment have the worst psychosocial health, while

those working part-time show the best health [49]. Contradicting this, some have

found that the presence of a partner, whether or not a woman has children, does not

affect health (801, while other cross-sectional findings show that marriage and

employment status interact, with married respondents reporting poorer health than

never manied respondents if employed, but better health if not employed (331.

The nature of the double day of work differs depending on the resources a

woman has to allow her to cope with her workload. The negative impact associated

with multiple roles is less evident in women in higher status occupations such as

managers and professionals, leading some to conclude that full-tirne work for young

mothers is detrimental unless there are adequate financial resources to ease the strain

of household responsibilities [14, 651. Working women with a partner who shares

domestic responsibilities, like women in higher status occupations who can afford to

purchase assistance with these duties, are in an entirely different situation than working

women who are solely responsible for the double day's work [il 50, 801. Higher status

occupations may allow more flexibiltty to facilitate the balancing of multiple roles [50].

For example, a Canadian study found that among working women with multiple roles,

many felt they would be better equipped to cope if they had more job security [80].

Some occupational groups are also more likely to comprise part-tirne workers (e.g.,

unskilled workers) thereby reducing time constraints which would otherwise make

balancing roles difficult [12].

Combining Social Roles With Structural Position

While some researchers in women's health have examined the interaction of

social roles and work status, and others have examined how a woman's structural

position in the occupational hierarchy contributes to work-health associations,

combining the structural position and social roles has only been done rarely. It has

been stated that the Arnerican tradition of examining social roles and the British

tradition of examining health by class need to be integrated [1 11 to consider women's

employment both as an additional role and as a structural variable relating to her labour

market position [49]. Others have recognized the need to consider how wornen's work

combines with not only their social roles and structural position, but also their material

circumstances [Il , 1 9, 491.

Studies which have considered the many facets of the relationship between paid

work and health have shown that women's work is not easily distilled to simple

associations. Women's health is differently associated with work depending on many

other interacting factors. Interactions occur between childcare responsibilities and work

status, showing, for example, that for mothers with children the only potentially

beneficial paid work is part-tirne [19,49]. l nteractions also occur between childcare

responsibilities and occupational status, wlh a complex array of results depending on a

woman's occupation, the presence of children and whether the work is full- or part-time.

For example, young mothers in low status occupational groups who work full-time

report much higher illness levels than high status mothers working full-time [14, 191. It

appean that matenal circumstances of the household also interact to increase

advantages associated with work. It has been shown that women with middle class

husbands have a particular advantage when working full-time (1 91. This advantage

may be because these women aie working because they enjoy it, not out of financial

necessity . Different Dimensions of Health

Beyond considering how work fits into the context of a woman's life when

studying associations between women's labour force activities and their health, it is also

important to consider the different ways in which the dependent variable, health, can be

examined. Researchers have noted different results depending on the measure of

health used in the study. Therefore, it has been recommended that one be eclectic in

selecting outcome measures [BO]. Certain dimensions of health have been more

strongly associated with occupational variables.

In particular, measures which tap into the psycholog ical dimensions of health

have been more closely associated with employment status and occupation (8, 1 91.

Such observations have led sorne to recommend that physical and mental health

measures be kept distinct to avoid masking associations [19]. Macran et al.,

investigated several dimensions of health with the assumption that sorne groups of

women would be vulnerable to specific dimensions of health. They, too, proposed that

more subjective measures of health, or measures that relate to psycholog ical health.

would be more closely related to curent social, structural and material circumstances,

at least initially. Their results showed a stmnger association of occupationai groupings

with these subjective and psychological measures [49].

Researchers interested in the associations between women's health and labour

force activities have shown associations with two-week disability [14], self-assessed

health [49,80], diseaseldisability [14,20,49], illness (1 9,20,49]. psycho-social well-

being [49], stress [80], fitness [20,49], and malaise (191. Since definitions of health

a vary, encompass many different dimensions, and various groups of women may be

unhealthy in different ways [49], it is essential that studies exarnining work status,

occupation and health use a variety of measures to capture these differences.

2.3 LIMITATIONS OF THE LITERATURE

Although the literature examining the associations between employment status,

occupation and health is extensive, there is r o m for further study. Some limitations of

the studies reported are noted in the following sections.

The Probtem of Health Sdection

An important limitation in many studies which have examined the relationship

between employment status and health is that they do not consider the role of health

selection. There is a two-way relationship between work and health. In addition to

work potentially causing an improvement or deterioration in health, women who are in

better health may be selected into paid work, while women in poor health may choose

not to work, or may find it more difficult to find or keep a job.

Some researchers have reported that health selection operates mainly on

employment status. There is not thought to be a drift down into lower status jobs as a

result of il1 health [IO], although some have suggested that health problems such as

back pain bring about a change in occupation. It is also possible that people with more

advantage with respect to education may have more Rexibility to change jobs (471.

Additionally, those working in manual occupations may be more likely to experience job

loss due to diminished health than those in professional occupations as different levels

of fitness are needed to fulfill the requirements of these respective occupations, and

different sick benefits, and variable union protection are extended to employees (491.

Several cross-sectional studies have attempted to control for health selection

a processes when examining the associations between work status and health through

the use of long-standing illness [8, 1 1, 12, 14, 19,49,50, 571. Long-standing illness is

considered as a measure of functional health that reflects how injury, disease or

disability impact daily life [ IO , 49, 501, and has been used as a measure of health status

[1 11. Depending on the study, individuals with limiting long-standing illness have been

either omitted, analyzed separately or controlled for in the analysis. Researchers using

such rnethods to control for selection differentiate between health status, which is

considered to be a person's long-terni health, and health state, which refiects their

current health. However, this dichotomy does not quite reflect the tnie situation. What

is treated as a dichotorny is more likely a continuum, where it is possible, but not

certain, that a person's present health state becomes their permanent health status.

Nevertheless, controlling for health selection in this crude manner has proved useful in

controlling the confounding effect of health status on the relationship between

employment and both physical and psychological health state, though it rnay

overestimate health selection processes.

Problerns With Employment Status

A major problem with the available studies is their different definitions of

employment status. Often no distinction is made between full-time and part-time

employment [19, 501. Yet, this is important because full-time and part-time divisions

reflect the amount of time exposed to the work environment, as well as the potential for

overload with other roles in ternis of time constraints, and these rnay directly or

indirectly influence health, and are related to occupation. There have been suggestions

that part-time work may, in general, be associated with health advantage more than full-

time work [12, 14, 19,491, with full-time work especially hazardous to employees in

lower-status occupations (1 41.

In addition to differentiating women according to whether they are full-time or

part-time employees or non- or unernployed, studies rnay need to take into account that

even these groups rnay not represent homogeneous categories. Reasons for being

non-employed rnay differ widely, work hours in the employed show a much wider

variation than just the full-timelpart-time dichotomy, and other factors such as the type

of job, the pattern of work hours and the other roles a woman combines with work, can

al1 have an impact on health.

Distinguishing between non- and unemployed women has proved difficult as

well. Sorne have suggested that women rnay underreport their unemployrnent. Even if

they would prefer to be working, women who find themselves unemployed rnay adopt

one of their other social roles, and therefore not report their main activity as looking for

work. Thus a broad definition of nonemployment, which includes the unemployed

would allow for the fact that many eady retired women or housewives rnay be so

defined because they are unable to work, not unwilling [12].

Problems With Occupation

With respect to occupation, both data collection and analysis have often been

insensitive to gender. Only recently has research been initiated at the population level

which attempts to remedy such problems when examining differences in women's

health according to type of occupation. Such research has corne largely from Britain,

which has traditionally wlleded information on occupation in health suiveys.

In the past, studies on the health of women in relation to occupational status

were actually considering their husband's occupation.

by their own occupation only if they were not mamed.

Such studies classified women

The rationale for this approach

0 was that class differentials were the important factor and a married woman's own

occupation does not affect her relative standing in society. Unfortunately, such studies

confuse household and individual status as welt as occupation and class. With the

numbers of women in employment increasing, ignoring women's own occupational

group is no longer acceptable [19,47, 501. More recent researchers have recognized

that dassifying working women by the occupation of their husband will disregard any

relationship between their own occupation and their health [50, 531.

But to classify women only according to the occupational group to which they

belong can still be criticized as a crude approach which poorly refiects the actual

content of a job [53]. For example, even with the same job title, differences in pay,

conditions of work and pattern of work hours can al1 differ. Such an indirect measure of

the actual aspects of a job can dilute or obscure associations between job conditions

and health [471. Nonetheless, crude occupational groupings do indicate that there are

health differences among wornen according to the sector in which they work.

Apart from the general problems associated with the lack of precision of

occupational groupings in identifying specific conditions of work, there have been

specific factors which interfere with the use of pre-existing occupational groupings to

classify women, especially when occupation has been regarded as a single indicator of

relative social position in society. Most often occupations have been ranked according

to the prestige associated with them or on a combination of educational requirements

and monetary rewards [471. However, such rathg systems have rarely considered the

gendered nature of the workforce, and thus are prone to many difficulties when

women's paid work is at issue. For example, occupations in which there is a

pieponderance of females, such as nursing, may not hold the same position of prestige

a on a scale considering the male labour force. In addition, occupational ranking systems

based on men's occupations do not adequatel y discriminate among occupations often

occupied by women. Researchers examining associations between occupational

groupings and the health of women have found that wornen's occupations tend to be

highly clustered in certain sectors and within the specific sectors, women are

segregated into specific jobs [53]. Thus many differences in women's health are

concealed by grouping quite diverse occupations together [50].

Finally, data collected by govemments can make it impossible to study

associations between occupation and health in wornen. Although information on work

is regularly collected for health surveys in Britain and Scandinavian countries, it is not

normally collected in the United States. In Canada, too, govemment data on occupation

have been shown to preclude the study of wornen [53]. Moreover, even when data are

available they are subject to major problems [48]. For example, in a study of

occupational rnortality in British Columbia (at the time the only province with information

obtainable on usual occupation from death registrations) between 1950-7 978, the

inclusion of women in the analysis had limited usefulness. Proportionai Moitality Ratios

yielded extremely imprecise measures for women as most were dassified as

homemaken (91%) and a fumer 1 % were not in the worMorce for a variety of reasons

[31]. In l976,42% of B. C. women over 15 were employed [il, and although this

number was probably lower in earlier years, it is unlikely that only 8% of women

evaluated in this study had a usual job besides being a homemaker. Women's death

registrations oflen state that the usual occupation is homemaker, particularly if a woman

is no longer working .

a Lack of Attention to the Context of Women's Lives

The focus on the different roles a woman occupies such as wife, mother and

paid worker, has been inconsistent in studies examining the associations between paid

work, occupation and health. The literature generally only counts women's paid work

when examining associations between work and health, while the unpaid work that

wonen do remains invisible. Research on women's employment and their health

should consider that paid work may not be the sole or even dominant activity in

women's lives, and that parental and marital status may not have equivalent effects on

wonen and men. Enough evidence exists to support the need to consider the

interaction between women's paid and unpaid work when considering their health.

Studies have also been criticized for equating domestic responsibilities with the

presence of children [19]. To remedy this flaw. one group of researchers constructed an

index to reflect the conditions of dornestic labour, which included the presence of

dependent children, as well as other care-giving duties and various indicators of the

material conditions in which dornestic labour is camied out, for example, access to a

garden, sharing accommodation and living density. No interaction between

employment status and the index was seen. However, given that the index

encompassed many distinct dimensions of a woman's dornestic conditions, the lack of

interaction should not have corne as a surprise. Broad indicators that atternpt to

combine many distinct dimensions can easily disguise interactions making indices

insensitive to domestic responsibilities that most strongly interact with paid work.

In addition to examining interactions between paid work and caregiver status,

there is also a need to consider interactions with a wornan's occupation. Some

research has found that multiple roles are not always stressful, and the suggestion has

0 been made that "many women appear to be very resourceful in coping with these

potentially confiicting dernandsn [65]. Examining social roles alone does not address

inequalities in who can afford to be resourceful, for example by purchasing help, or

whase resourcefulness is facilitated, for example, by having a flexible work

environment. Failing to analyze a woman's structural position in the occupational

hierarchy leads to victim-blaming where we are left wondering why not al1 women are

so "resourceful".

In sum, although some studies have considered the interactions between

women's unpaid domestic and paid work and their structural position, these conditions

need to be considered consistently or the results will conceal the cornplex associations

between work and health in women's lives.

2.4 IMMIGRANT WOMEN, WORK, AND HEALTH

Although many health issues have been studied in immigrant women, research

examining how their paid work is related to their health, particularly at the population

level, is sparse. Quantitative studies on immigrants' health which have considered work

often have not differentiated women from men, or have not included wornen in the

analysis. However, official çtatistics, several local qualitative studies, and governmental

task forces have raised concem that specific conditions of immigrant women's labour

force activities place their health at a disadvantage. Additionally, studies of immigrants,

though not focusing on work per se, do show that the health of immigrant wornen differs

from that of immigrant men and native-bom women. Selected studies from the vast

literature on immigrant's health will be reviewed in the sections that follow, some

focusing on the health of immigrant women, some on their labour force characteristics,

and some considering associations between paid work and health, though not

a necessarily focusing on women, since few studies of this kind exist.

The Health of Immigrant Women

Both rnorbidity and mortality data have been used to examine the health status

of immigrants in Canada and other Westem countries. These studies have found

divergences between foreign and native-bom women, as well as differences between

male and female immigrants.

Examined as a whole, immigrants in Canada, like those in other Westem

countries, have a lower mortality rate than the Canadian-bom, though this survivorship

advantage has been noted to disappear at post-retirement age. However, separately

examining immigrant women has revealed higher death rates compared with the

Canadian-bom [78]. Immigrant women have also shown more frequent increases than

men in mortality from suicide compared with their birth countries, leading some to

conclude that migration to Canada is more detrimental for women than men [43].

The mortality patterns in immigrant women and men are supported by studies

that consider morbidity. Not surprisingly, these have found that women display poorer

health than men, whether physical or mental health measures are examined. A recent

study of newcomers to Canada which found men to be happier and under less stress

than women [51] is not unlike other studies which have found correlations between

immigration and distress, psychological syrnptoms and psychiatric morbidity [QI 1 5, 241.

However, no conclusive evidence directly links migration per se with mental illness, so

other risk factors must be wnsidered [4q. For instance, challenges in adapting to a

new society, including changes in the material, social and cultural environment and

lifestyle may explain elevated rates of mental health problems in immigrants. However,

these altemate explanations have not been tested empirically.

a Studies from Canada and other Westem countries that have examined physical

measures of health have also found that although immigrants as a whole have better

health than the host country populations. this does not always generalize to immigrant

women. Fernale immigrants have been found to suffer from many physical heaAh

disadvantages compared with men [84]. For example, a greater proporüon of male

immigrants to Canada were more satisfied with their health than in their home countries

and reported fewer chronic conditions and disability compared with female immigrants

[26, 511. Compared with the native-bom, no consistent pattern is seen in immigrant

women. For example, South Asian immigrant women in Glasgow reported more

chronic conditions than native-born women [84], while the Canadian National

Population Health Survey (NPHS) found that immigrant women displayed fewer chronic

conditions than the native-bom, although the advantage was smaller in long-term

immigrants [26].

Little understanding of immigrants' health has been, or can be, gained from

examining immigrants as a relative1 y homogeneous grou p. In particular, the

experiences of immigrant women cannot be subsurned under those of immigrant men.

The complexity of immigrant wornen's lives, particularly their diverse social, cultural and

material conditions, must be considered when examining their health [2, 7, 27,281.

Immigrant Women, Employment Status and Health

Because most women enter Canada as family class immigrants dependent on

sponsors, there appears to be an assurnption that they do not work for pay [36,30].

Therefore, little direct attention has been given to the role their labour force activities

play in their health. Thus, while acknowledging that female immigrants often experience

higher levels of distress and poorer health upon migration, many researchen have not

considered their occupational rales important, although for men, occupational and

employment status are thought to be particularly relevant [24,89].

Although they are not considered destined for the labour market, many family

class immigrants do enter the workforce [28]. In fact. immigrant women have been

reported to have a higher age-standardized employment rate than the Canadian-born

[30,36], with 62% of immigrant women aged 15-64 employed in 1991 [32].

Additionally, immigrant women are more likely to be working full-tirne than the

Canadian-born, with 77% of ernployed immigrant wornen working full-time in 1991,

compared with only 72% of the Canadian-born [32]. Immigrant women working full-time

in low status occupations often work extrernely long and irregular hours to earn enough

to rnaintain their families [3, 6, 301.

Studies considering employment status in conjunction with other factors in

immigrant women found that being employed was the most important factor contributing

to a high sense of well-being and alleviated feelings of wony and depression in both

male and female immigrants [73]. Suitable employment was associated with better

access to health care [39], strengthened social relationships, and the development of

novel skills required to manage daily life in the new country [4]. Compared with

immigrants not working outside the home, qualitative studies found that even those in

low status jobs had increased feelings of independence, autonomy and a sense of

contributing to the family that eaming their own income provided [2, 621. However, low

status work held no intrhsic value, and the benefits derived were suggested to be

related solely to the incorne eamed [4].

Despite higher levels of employment, and a greater likelihood of working full-

tirne, cornpared to the Canadian-bom, more immigrant women who are not currently

ernployed are seeking paid work; therefore, their unemployment levels are higher. This

is true at al1 ages, but particularly so for young women, recent immigrants, and those

belonging to ethnic minorities [25, 32, 301. As with the general population,

unemployment may be a source of stress for immigrants, particularly recent ones [24,

36. 511. However, conflicting evidence for physical health has also been reported. A

longitudinal study of migrant workers (men and women) in Germany found no causal

effect of unemployrnent on health, and the authors suggested that even their

longitudinal study was limited; factors which may influence the relationship such as type

of job and level of benefits were not considered [29].

Immigrant Women, Occupation, and Health

The positions occupied by immigrant women in the occupational hierarchy have

been well-described [30,32, 831. Despite this, few qualitative studies have examined

the labour force position of immigrant women in relation to their health status, and even

fewer studies have examined such associations quantitatively. However, based on

existing evidence, the association between poorer health , both physical and mental.

and lower occupational status found for women in general also appears to hold for

immigrant women, with their difficulties compounded by race, and, for some, obstacles

to leaming an official language [2,21, 22,271.

Like their native-bom counterparts, immigrant women are clustered in

occupations traditionally held by women in Canada. For example, in 1991, more than

half of employed immigrant women worked in clerical, sales or service jobs [32] where

they have been reported to occupy the lowest strata [2,4,30, 561. In addition.

immigrant women, whether due to a lack of skills or ocwpational downgrading

experienced upon migration, are relegated to low-skilled, low-paid manual occupations

more often than the Canadian-bom, and the segregation of immigrant women in these

job ghettos has been a point of concem [t 8,301. For example, employed immigrant

women were four times more likely to work in jobs fabricating. assembling and repairing

products than the Canadian-born [32], and the proportion of new immigrant women

being channeled into such occupations has been increasing [71]. Neariy half of al1

employed I ndoGhinese women have been reported to work in product fabrication.

assembly and repair occupations [83]. These occupations are associated with poor

health in women in general, and there are indications that similar associations also hold

true in immigrants. Data from Europe have shown working class immigrant men and

women (in skilled and unskilled manual jobs) ta have higher levels of long-term illness,

working impainents, il1 health, physical and mental work stress and work accidents

[76]. Unskilled or semiskilled immigrant workers also reported lower health satisfaction

than skilled workers or salaried ernployees [29]. Labour migrants were said to be

employed in sectors where the native-bom were unwilling to work due to harsh working

conditions. and these workers paid for this in later life with increased levels of illness

[29. 761. Socioeconomic deprivation, which is related to work status and occupation,

was one factor cited in the high rates of coronary heart disease deaths in South Asians

especially longtirne residents, in Britain [85l. A similar situation has been depicted in

Canada.

Foreign-bom workers have been an important, perhaps even sole source of

labour in positions where, because of the types of tasks, low pay, difficult conditions of

work, and direct hazards, the Canadian-bom are unwilling to work [21,22,23, 301. The

absence of union organization, and sometimes, the absence of minimum wage

protection has also been said to contribute to poor working conditions [23,271.

Immigrants in some specific sectors-fam workers, garment workers, plastics workers,

domestics, chars and cleaners-have been the main supply of workers, for these exact

reasons, and their health has been the concern of several reports [21, 22.23, 301.

Several qualitative studies have examined the health of Canadian immigrant

women in low status occupations. The poor conditions under which they worked, the

instability of their jobs, and the low status accorded to their occupations were said to

diminish their well being, and contribute to psychological distress and mental disorders

[2,4, 23, 451. Women described the physical and mental strain of their work, time

pressures, unreasonable workloads, being constantly watched by supenrisors, and

having little social contact with other workers, and they connected the conditions of their

work with their own poor health [4, 281. While social contact with peers may be a

positive feature of working in an ethno-linguistic job ghetto [28], the nature of their

employment generally did not give these women positive reinforcements such as

increased social support or the self-esteem nomally associated with working, and their

work was even a source of embarrassrnent [4,7l.

Cornbining job pressure, lack of mobility, poverty and poor health compounds

stress [2,7l. The economic needs of some immigrants make them susceptible to

exploitation in work hours, conditions of work and wages [23, 301. Immigrant women in

low status, physically demanding jobs, unlike women in higher status occupations,

lacked fringe benefits such as paid sick tirne, medical and pension plans, paid

vacations or good wages, rnaking it difficult or impossible to keep medical

appointments, or purchase medical provisions [3, 5,28,551. They could not move into

other jobs or retire early to allow them to manage chronic illnesses [2,28], and the

infi exibility and poor conditions of their work made it difficult to care for their heaW, and

a in sorne situations, were a direct ham [5].

Job instability can add to poor conditions in the workplace by forcing workers to

choose between an unhealthy, dangerous workplace, or not working at all. The

combination of poor work and economic conditions, along with the threat of

unemployment made it difficult for some women to manage chronic illness. Women

recognized that their difficulties complying with treatment regirnens and inattention to

their own health were related to their economic needs and fear of job loss [3]. Fear of

job loss made sorne women in lower status occupations reluctant to inform employers

of their health conditions or monitor their illness during working hours, sometimes

putting their health at risk on the job [5]. Remaining employed was a priority over illness

management [5].

Underemployment is another concem for immigrant women [30, 361. Well-

educated or professional immigrant women may find that their education, skills and

foreign experience are not recognized, leading to downward rnobility in the workforce in

Canada [4, 7, 301. They continue to encounter restricted rnobility and few advancement

opportunities once in low status occupations, and they do not catch up with the

Canadian-bom in later years (301. In some cases, an immigrant's level of education has

been negatively related to adjustment level [24, 891, consistent with the suggestion that

the interaction between one's aspirations and one's resources to achieve them rnay be

more important to mental health than each dimension separately [40]. Women's

elevated suicide rates may be explained by the status inconsistency associated with

their greater tosses in occupational status compared with males [43]. Sorne qualitative

studies found reduction in professional and socioeconomic status to be the most

distressing part of the immigration and resettlement expenence [lq, while others have

suggested that status demotion causes diminished self-esteern (1 71 and is a risk factor

for poor mental health [24.36].

In 1991, employed fernale immigrants were alrnost as likely as Canadian-bom

women to be employed as professionals. Nonetheless, visible minority women were

less likely to hold professional or managerial positions, despite their higher level of

university training [25, 321. Professional workers with skills transferable to the host-

country's labour market are at an advantage over immigrants who lack such

qualifications as they find employment and gain social acceptance more easily [45].

However, some research has shown that immigrant professionals, like non-

professionals, also occupy marginalised labour market positions, and women are even

more likely to be engaged in marginal activities. Thus, even if immigrants can work in

their profession, they may fiIl the least desirable positions [63].

In sum, the data suggest that because of the different pattern of employment

seen in immigrant women as cornpareci with native-born women, especially their

occupational segregation and marginalization, work may not have the same association

with health in immigrants as in the native-bom.

Combining Domestic and Paid Work in Immigrant Women

As presented eariier, working women living in poor material circumstances may

lack the resources needed to successfully balance their multiple activities. Although

immigrant women have some unique circumstances, they are like the Canadian-born in

their need to balance paid and unpaid work, and many immigrant women carry out

2. While not all visible minority women are bom outside Canada, in 1991, 79% over the age of 15 were, thus the disadventages associated with being a member of a visible minority are experienced by many immigmnts, especially recent ones [25l.

these activities in poor economic circumstances. Some women combine work and

dornestic roles for the first time in Canada [4], while for those with experience balancing

multiple activities, doing so in a changed environment could pose a challenge [871.

As with wornen in general, combining childcare, unpaid housework and paid

employment can be a source of stress, fatigue and poor health for immigrant women [4,

27,28,45]. Immigrant women and their families saw childcare and housework as a

woman's responsibility with others "helpingn, while their paid labour was viewed as

"assisting" with family finances [4, 7, 791. Reflecting these priorities, their work

schedules were arranged to accommodate farnily responsibilities where possible, with

women putting in a full day's work at home and in the workplace [7, 301. Variations in

sharing household work occurred even in extended families [5,7 though some have

suggested that wornen older than fifty often immigrate to care for their grandchildren

[871. Long hours of paid work, childcare, and dornestic work did not permit women

leisure time (41 let alone time to look after their own health, even when faced with

chronic illness [6]. Furthetmore, after domestic and paid work, little time remains for

language training or upgrading skills contributing to lack of job mobility [3, 301.

The marital role of immigrant women can also influence health. Overall,

immigrant women are more likely than the Canadian-bom to be partners in two-spouse

families with 69% of al1 immigrant women aged 15-64 being rnarried compared with

61% of the Canadian-bom. Visible minority women, by contrast are less likely to be

rnarried (56%). Canadian-bom, immigrant and visible minority wornen are al1 equally

likely to be single parents (8%).

Family can be a source of support or of conflict. Marriage is associated with

a decreased risks of suicide [43,45], but family wnflicts due to varied rates of

assimilation or with traditional role revenal have been suggested as reasons that recent

immigrant women suffer more stress, poorer health and less happiness than men [5q].

Stress associated with migration can strain family relationships, reducing feelings of

support, especially when few alternative supports exist outside the home (41. Women

are often further separated from their extended families, which would normally be a

source of support. Furthermore, women who are legally dependent on their husbands

by their sponsorship can be even more dependent than they may have been in their

home country [27, 28, 30, 661. Despite these risks in mamed women, single migrants

and immigrants separated from their spouse or children were at special risk for mental

disorders [24, 891.

Ethnicity and Immigrant Health

Although immigrants from Europe represent the largest proportion currently living

in Canada, major shifis in country of birth have occurred in recent years [16, 321. This

rapidly changing cultural mosaic makes ethnicity a concern in studies of immigrants

since, as some have suggested, the health status, behavior and health care needs of

different groups may be unique [9.26].

Some studies examining the health of immigrants found ethnicity to be an

independent dimension influencing illness at a level equal to social class and Iifestyle

[76]. It has been stated that under certain circumstances, 'race and class may overlap

to generate a class structure along racial lines* (61, and studies from several Western

countrîes have reported such marginalization. These find that immigrant groups,

especially those from the Third World who live in marginal social and cultural sectors in

the society, suffer a triple burden through the effect of ethnicity 3. low social position,

0 and poor material conditions [2, 30, 37, 751.

The Canadian labour market is characterizad by similar occupational, gender

and racial stratification [23]. The life and work experiences of white women and women

of color differ [66], placing nonwhite women at a disadvantage (41, though structural

racism can be cornplex to identify. For example, when there is little competition for

undesirable occupations from the Canadian-born, and the opportunity for advancement

is nonexistent, many women do not feel discriminated against in the workplace [4].

Nonetheless, racism can be seen in the segregated nature of the labour force [23] with

direct evidence apparent in the difficulties sorne researchers have encountered when

trying to match white women with eth nic minorities on occupation. Few ethnic minorities

were in professional occupations, while few immigrants from the United

States work in product fabrication occupations [4, 7, 301, congruent with the idea that

discrimination is causally prior to socioecunomic status [86].

Discrimination based on language and ethnic divisions has been directed at

white, and nonwhite groups, affecting unskilled immigrant wornen [66]. Additionally,

while some sectors of the economy confer disadvantage to Canadian-bom and foreign-

bom alike, foreign workers, because of their tenuous legal-political status are at a

greater disadvantage. Some authors argue that the three year residency requirement

before immigrants are permitted to apply for citizenship may jeopardize health by

3. Studies have considered ethnicity as a cornplex concept that encornpasses: The efect of violent uprooting, migration, disnrpted social and cultural connections with the home country, the encounter with a ditfemnt society, the process of accuitumtion, discrimination and xenophobia. * [76]; fhemfore, at issue are not only an individuai's charactedstics, but also the host society's reection to the individual, including mcism. ~ 3 1 .

making them susceptible to exploitation in working conditions due to their status

uncertainty during this period [22,36].

2.5 LIMITATIONS OF THE LITERATURE

Complexity of Immigrant Population

A major criticism of many studies of immigrants is their lack of attention to the

heterogeneity of this population. Multiple relevant pre-migration and post-migration

variables are rarely controlled for in a single study [24], with some studies even lacking

data on the most basic factors, such as age [51]. Others have narrowly focused on

family or cultural characteristics thought to contribute to poor health, ignoring alternative

explanations, for example the influence of class, econornic. social and material

circumstances, paid and domestic work, gender, and the health selectivity of the

immigration process [2, 5,21, 27, 281. lgnoring this complexity can yield conflicting and

uninterpretable results.

Furthermore, the epidemiologic and public health approaches that try to reduce

the complexity of the immigrant population to measurable variables to control in studies

are problematic. Some researchers in the field have even gone so far as to suggest

that translation of some concepts into variables is virtually impossible [40]. l mmigrant

status, ethnicity, and length of stay are commonly used variables which are subject to

such conceptual problems.

Immigrant Status

When studying health in immigrants, researchen have often failed explicitly to

define the meaning of "immigrant" [9]. Most often, 'immigrant" is operationalized as a

discrepancy between country of birth and country of residence. Some studies exclude

migrant workers and refugees from this group, while others include children bom to

0 migrants and immigrants. Operational definitions, while convenient for some purposes,

have been said to be contrary to "real lifen definitions of what it is to be an immigrant

that may relate both to where a person works and to her health. It has been proposed

that the "real life" terni "immigrant" has both race and class aspects: "Women who are

considered immigrant women are primarily non-white women from the Third World and

Southern Europe ... White, middle-class professional women from Britain and the United

States are not usually considered "immigrant womenn either by themselves or others"

[18]. When concerned with immigrant women's health, previous studies suggest that

the group at most risk for poor health would be the one marginalised by the "real life"

class- and race-based definition. Moreover, while immigrant women do share some

similar attributes and circumstances, much variation in experience exists, leading some

to recommend that the concept of "immigrant womann be defined situationally, with a

flexible meaning, rather than defining these women taxonomically, which can foster

incorrect generalizations [27, 281. Studies failing to consider the different

circumstances of immigrant women's lives cannot provide insightful information into the

association between their work and health.

CulturdEthnicitjt

Studies of immigrants in the epidemiological and public health literature often

use ethnicity as a variable, even though it is a multifaceted concept that is dificult to

define and operationalize. Indeed, it has many definitions. An ethnic group, in

epidemiology, has been defined as: "A social group characterized by a distinctive

social and cultural tradition, maintained within the group from generation to generation,

a common history and origin, and a sense of identification with the group" [46]. While

sorne studies target certain ethnic groups, suggesting that their health needs, patterns

of illness, concepts of health, and lifestyles may differ from the general population, at

the same time they acknowledge that differences may be exaggerated or wrongly

attributed to ethnic factors [84]. Interestingly, in the epidemiologic and public health

literature, altemate explanations are rarely sought. Treating "culture" and "ethnicity" as

static, measurable, and objective social characteristics added on to other variables to

explain differences in health as many epidemiologic studies do, ignores the context of

immigrants' lives-their material and economic circumstances, social position, and

health experiences [3, 6, 271. Additionally, categorization assumes "ethnicity" to be a

valid concept that can be correctly identified and classified [34]. However, validation of

the concept of ethnicity has been said to require an understanding of a person's social

identity as well as changes in this identity [34].

In other fields, researchers have argued that " culture ... is not autonomous or

static, coming in a discrete bundle to be passed on to the next generation, but is a

cornplex, dynamic phenomenon closely linked to the political, social and econornic

institutions of a society, themselves dynamic and changing over time ..." (271. While

cultural commonalities may exist, knowledge and practices are also affected by a

penon's life circumstances. Understanding culture as a dynamic process tied to the

local context of a person's life. allows for a great deal of variation in ideas and practices

[27l. This variation has been addressed in the qualitative Iiterature, where loss of

status, downward mobility, current work conditions, unemployment, unfavorable

socioeconomic conditions, thwarted expectations, financial difficulties, and redefinition

of roles (4, 28, 371 have been said to contribute more to immigrant women's health in

situations where culture has been implicated. For example, patterns of illness

management in immigrant women were found to be a way of coping with material

conditions and were not attributable to ethnicity, culture or custornary lifestyles.

Similarities in immigrant women's lives, such as having the same occupation, as

opposed to specific cultural characteristics, can be more related to shared health

experiences [3, 6, 7,27, 281. Others have suggested that health problems are open to

redefinition based on conditions in the receiving country rather than being culturally

bound and immutable [27].

In sum, the current usage of culture and ethnicity in the epidemiologic literature

has limitations. The discrepancies between the complexity of the concepts and the

simplicity of the variables used to measure them are rarely discussed. Qualitative

research may in this situation complement quantitative research [58]. Additionally, one

must fully appreciate the economic, structural, social and cultural context of immigrants'

lives when considering their health [271. Thus taking the analysis beyond one of culture

and ethnicity is necessary.

Length of Stay

How much time an immigrant has spent in the host country, the length of stay,

while sometimes accounted for in epidemiologic studies, adds further confusion to the

Iiterature on the heaith of immigrant women. Difficulties with this variable anse from the

diverse processes it reflects, making its translation into a conceptual variable and

placement into a theoretical frarnework problematic [40].

The association between length of stay and health has been suggested to be

due to many factors including: longer exposure to the cumulative stress and trauma of

poor socioeconomic and work conditions in the host country [24, 37, 76, 841, increased

adaptation, acculturation or convergence to social and cultural patterns of the host

country [39,43] including changes in diet and lifestyie [26]; and cohort effects [43] or

a secular trends such as motivation for and circumstances of immigration [15], differential

selection for health, skills, education and other desirable traits [26, 40, 781, or shifts in

immigration source countries [26]. Given the many processes that length of stay can

reflect, it is not surprising that its association with health has been inconsistent in both

strength and direction. For example, while the length of U.K. residence was associated

with poorer health status among South Asians [84], and length of Canadian residence

was associated with poorer health in both European and al1 other immigrants [26],

Russian immigrants to lsrael showed better health with longer length cf stay [9].

Additionally, differential rates of adaptation in family members show that unique

influences on the adaptation rate exist which can affect family members differently [9,

24, 891.

Because distinguishing among the different dimensions combined into the single

variable length of stay is impossible, interpretation of the associations between this

composite variable and health is limited. The different dimensions it has been

proposed to reflect are mutually confounding; therefore, implicating one of them as

being associated with health would require proper control of the other dimensions,

something that may be impossible within the frarnework of an epidemiologic study.

Healthy Immigrant Effect

Any study of the relationship between work and health in immigrants must

consider selection factors. Immigration regulations may directly or indirectly favor

healthier individuals or those with better wping resources or adaptive capability

compared with people in the home or receiving countries. This will create a "healthy

immigrant effecf [26,29,40]. For example, in Canada, potential immigrants are ranked

on a point system that includes factors such as employability, income and education

0 which are associated with better health [26]. Immigrants also undergo health screening

[26, 51, 791 which favors those with better health. Self-selection also plays a role [40].

Not only is il1 health a barrier to migration [76, 26, 371, but migrants who have dificulty

adapting to the receiving country may retum to their homeland [79]. Thus, direct

comparisons of immigrants with home or host country populations will likely show a

healthy immigrant effect. Health selection is evident in immigrants to Canada [26]. Few

recent immigrants have severe physical problems, chronic illness. long-terni disabilities

or activity limitations [26, 511, though reduced levels of health are seen with longer

residency in Canada [26], as elsewhere.

The selection process that immigrants undergo reveals that finding appropriate

comparison groups whether from the general population or the native country may not

be possible. Only specific population subgroups of the hast or the origin country may be

suitable for companng health status [40].

Assessrnent of Health

In the literature examining associations between work and health in women in

general it was noted how these were sornewhat reliant on the dimension of health being

evaluated. In immigrant women, selecting health outcornes to evaluate rnay be further

cornplicated by the fact that concepts of health, illness, disease and disability may differ

cross-culturally [27,28], as well as between women and men [6]. The equivalence of a

measure across groups depends on the conceptualization and reporting in different

cultural groups, and etiquette may also play a role [89]. Self-reports of health are also

affected by individual perceptions and interpretations of symptoms, and willingness to

report illness (61. Concems over the cross-cultural validity of quantitative measures

used in surveys that include immigrants have been voiced, and the validity of sunrey

a instruments is rarely assessed specifically in an immigrant population. Studies

applying survey instruments used on the general population to immigrants have noted

differences in reporting in different ethnic groups [17, 81, 84, 891.

Qualitative studies avoid some validity problems since they rely on respondents

to give meaning to their answers. Replies need not al1 have the same meaning for al1

respondents as is necessary in quantitative surveys [52], where systematic differences

in concepts make interpretation difficult and differences may not reflect tnie

associations. The quantitative studies in the literature generally did not adapt

measures cross-culturally. Rather, the use of measures, for example, the number of

chronic conditions [9, 291, self-assessed health [9,29], long-term illness (751, and two-

week disability [29, 751 was justified by their widespread application in many different

countries.

A related consideration in the study of immigrants is the use of translators or

interpreters. It is important that individuals who are unable to communicate in the

language of the study not be excluded, as these people may be at special risk for

adverse health. For example, women who face language barriers risk being

unemployed, working in low status jobs, and having unmet heath needs. Although the

majority of immigrant wornen in Canada speak an official language [32], 8% of

immigrant women in 1991 could not conduct a conversation in either French or English.

Recent immigrants are less likely to have time to acquire an official language and this is

reflected in the finding that 13% of those who arrived in the 10 years prior to 1991 could

speak neither official language. Translation of questions into the rnother-tongue of

these individuals is helpful. However, if this is not done correctly, this too can introduce

subtle distortions in a measure. For example, literal translation is not recommended, as

a feelings, disorders or symptoms may not be expressed the same way in different

languages. Back translation should be done to ensure that the desired meaning is not

lost, and finally, reliability and validity should be re-tested as there is no assurance that

they have remained constant [74]. Studies in this literature review sometimes employed

translation [29], back-translation 1751, bilingual interviews [84] and interpreters.

However, reliability and validity of suwey instruments were not retested on immigrants.

The qualitative studies cited here employed interpreters to conduct and evaluate

interviews and are also prone to difficulties associated with the translation of responses.

Measuring Occupation

Another measurement issue that must be addressed is the assignment of

occupational groupings. As with cornparisons between women and men, it is likely that

immigrant women do not always share the same risks with the native-bom even when

they work in the same sector of the economy. Regardless of holding the same job title,

immigrant women are said to hold marginalized positions. Thus, equivalent values on

traditional measures of social position may not represent the same socioeconomic

status for immigrant, as for native-bom, women [86]. Furthemore, the status of

occupations may be assigned differently in different cultures [471. Thus, direct

comparison of immigrant and native-bom women is fraught with difficulties when c ~ d e

occupational assignments are used.

Data Quality

Missing information on key variables is a cornmon problern in studies of

immigrants. Studies relying on vital statistics from the Çtatistics Canada Mortality Data

Base (SCMDB) have found that country of birth information is often incomplete, with

many subjects having 'unknown" or missing data [79]. Offcial records also have Iimited

information, as death certificates usually only have data on age, marital status,

birthplace and cause and place of death. No information is available on length of

residency or occupation, and ethnicity has been discontinued as a variable in the

SCMDB [79].

Another consideration is that of purposeful non-response in surveys. Some

immigrants may be unaccustomed to being surveyed or fearhil of govemment surveys,

and may mistrust the interviewers, with the degree of mistrust being related to their past

experiences with govemment. Responses rnay be inhibited when people know data are

being coliected for the govemment [48]. Levels of item-specific non-response that may

indicate the acceptability of different survey questions were not reported in the studies

cited for the immigrant population. However, one study which questioned immigrants

about their reasons for non-response found that some felt that the survey was too long

or the questions too personal, while others believed it was a political conspiracy to

deport them to their homeland, or that health surveys were only for the educated or sick

people [51]. If non-response is related to immigration factors such as time since

immigration or country of origin, bias or generalizability problems could be introduced to

studies relying on these data.

Data quality is also affected by the small number of immigrants in any given

survey, particularly when random samples of the population are taken [26, 851. In

several studies, srnall numbers prevented detailed subgroup analyses [26], prevented

separate analysis of women [38], and required several distinct countries of origin to be

collapsed into one [26,75, 791, reducing both precision and generalizability. For

example, in creating such groupings, race and ethnicity are often seen as synonymous.

even though immigrant health studies have shown that this assumption does not hold

a [59]. Aggregating ethnic groups has been said to create over-generalizations about the

health behaviors of certain groups, ignoring that they differ greatly in their history,

culture and language [39]. Despite limitations in collapsing groups, some have justified

the practice on the basis of shared language and cultural and political adjustments and

the need for sufficient numbers to permit statistical analysis [75, 761.

By contrast. qualitative studies which are local avoid these problems. However,

selecting specific sub-populations [6, 7] which may not represent the different positions

that immigrants occupy, can produce detailed descriptions, but only in limited settings

[52]. While this may seern a valid concem on epidemiologic grounds, it is important to

question the practice of generalizing aspects of immigrant health. Setting is also

relevant to immigrant health, with some public health researchers going as far as to

recornmend considering each migration as unique [40].

2.6 SUMMARY AND OBJECTIVES OF DATA ANALYSIS

The literature on women in general has revealed that the association between

women's paid work and health is a cornplex one (see Appendix 8) which requires not

only an analysis of structural position in the labour force, but also consideration of

material circumstances and unpaid work in the home. Furthemore, while cross-

sectional surveys provide large-scale data required to conduct soch analyses,

limitations in the design, specifically the temporal sequence of the relationship between

work and health must be taken into account.

Previous research on work-health associations in women in general provides a

point of departure for similar studies on immigrant women. While immigrant women

have many commonalities with native-bom women, such as their dual responsibilities of

paid employrnent and unpaid domestic work, differences in their patterns of

a participation in the paid work force, the positions they occupy in the occupational

hierarchy, and the potential confounding influences of length of stay or ethnicity on their

health rnay contribute differently to the association between their work and health.

Furthemiore, immigrant women, unlike native-boni women, are selected for health

directly or indirectly through the immigration process itself, impeding a direct

comparison with native-born women.

Clearly, when considering the associations between work and health in

immigrant women, many factors should be taken into account. Although a cornplete

analysis may be impossible, this study will attempt to alleviate some flaws of past

studies by examining a variety of factors. First. ethnicity, although included, will not be

the ptimary variable of interest. Rather, the associations of immigrant women's

employment status and occupation with health are the main interest. The flexible

definition of immigrant women, unique to different settings, used by qualitative research

approaches cannot be applied here. Nonetheless, attention will be paid to the contexts

in which women work (through the occupation variable), in which they live (through the

income adequacy variable), and their social position will also be considered (through

the inclusion of education and ethnicity as variables). Gender-specific considerations

such as womenJs dual roles in paid and unpaid work will also be examined. Finally, the

potential effects of health selection in confusing the associations between work and

health and the additional concerns with the lack of comparability of immigrant and

native-bom individuals with respect to occupational groupings underlie the absence of

an extemal comparison group in the study reported in this thesis. L

3 METHODS

3.1 STUDY DESIGN AND DATA SOURCE

The design of this study is cross-sectional. The data used were previously

collected from individuals for the 1994-95 National Population Health Survey (NPHS) of

private households. The NPHS was a nationwide interview-based survey of 26,430

households from the Canadian population including men and women of al1 ages.

Questions on immigrant health permitted the opportunity for this subpopulation to be

analysed [69].

3.2 SAMPLING IN THE NPHS AND THE OSE OF WEIGHTS

A stratified two-stage sarnpling scheme was used to select households in the

NPHS. First, homogeneous strata were formed and independent samples of clusters

were selected from each stratum. Each province was divided into 3 types of areas from

which separate geographic and/or socioeconomic strata were formed. In most strata,

six clusters (usually Census Enurneration Areas) were selected with a probability

proportional to their size. Then, dwelling lists were prepared for each cluster from

which households were selected. One person was randomly selected from each

household. The sampling fraction was increased for single-living individuals. Details of

the sampling can be found elsewhere [70,771.

Since the NPHS design was complex, having stratification, multiple stages and

unequal probabilities of selection of respondents, each individual surveyed was given a

weight based on the inverse probability of seleding the panel member in the household

mulüplied by the inverse probability of selecting the household. Thus, each person

sampled "representsn several other persons not in the sample [77l.

Considerable debate exists over the use of weights in analysing cornplex

0 surveys and the issue remains unresolved. Some argue that weights are needed

othewise derived estimates, including those from linear or logistic regression, will not

be representative of the survey target population. This would make inference from the

study population to the target population enoneous [70]. An opposing view contends

that weighting, while relevant to policy research, is not relevant to scientific research;

scientific research is said to be wncemed not with the experience of any specific

community for a particular period of tirne, but rather with the relation of interest in the

abstract without a specific place or time referent. Thus, one specifies the study base by

choice and so long as this base has representatives of the relation of interest, its

representaüveness of some specific target population at some specific time is

unimportant [54]. Consideration of the complex design and probability of being sampled

is both unnecessary and wrong, and standard statistical techniques should be used

P l * Weights will not be used in the analysis reported in this study for several

reasons4 . The women studied fall into several different categories of work status,

occupation and health. Their selection was done independently of health outcome, thus

differential selection according to both independent and dependent variables is unlikely.

Evidence in the literature indicates that immigrants in other Western countries

often have similar experiences to those in Canada, and Canadian immigrant women

have been consistently over-represented in low status occupations for many years.

Thus, inference is not being made specifically to the 1994-95 Canadian population of

immigrant women.

4. Although we@hts were not used in the analysis descnbed in Mis ihesis, equivalent

a tables for weighted Anal models c m be found in Appendix 7.

a 3.3 METHODS OF DATA COLLECTION

Data collection for the NPHS proceeded in several stages. First, a

knowledgeable person in the selected households answered general questions on each

household rnember. Subsequently, an approximately one hour long, in-depth personal

interview was conducted on a single randomly designated person over the age of 12 in

each selected household. Many interviews started in penon, but were completed by

telephone either because the selected respondent was not available at the initial visit or

the inteiview length prevented completion in one contact. Proxy reporting was allovved

only if the selected respondent was il1 or incapacitated (4% of the information collected)

[70]. To avoid non-response due to language problerns, questionnaires were translated b

into the languages of several major immigrant groups [70]. The questions used to

obtain the data relevant to this particular study are found in Appendix 2.

The NPHS utilized computer assisted intewiewing; therefore, the logical flow,

type of answer, minimum and maximum values and instructions for cases of non-

response were al1 pre-programmed. This allowed inconsistencies to be immediately

corrected. As well, reference dates for the questions were automatically registered,

thus customizing the questionnaire for a respondent [70]. The survey was tested on

focus groups and in two field tests to determine length, quality, clarity and sensitivity as

well as to predict response rates, evaluate the computer program and train interviewers

(70, 771. However, no testing specific to the immigrant population was reported.

3.4 MISSING DATA

People refusing to participate in the NPHS received a follow-up letter stressing

the importance of the survey followed by further attempts at recruitment. Dwellings

refusing to participate were not replaced. The household response rate in the NPHS

was 88% and the selected person response rate was 96% [70]. The amount of total

non-response specifically for immigrants is not known.

Partial non-response to the NPHS (Le.. question-specific non-response) was

said to be "basically non-existent" [70] with the occasions of it attributed to poor

comprehension or misinterpretation of a question, refusal to answer, recall difficulties,

or an inability to provide non-proxy information. Partial non-response was seen in the

study population of working-age immigrant women examined here. Those (5.7%) for

whom it was not possible to assign a value for mental distress were removed from the

analysis. By contrast rather than omitting respondents with information missing on the

independent variables (other than those required to assess work status or occupation),

these women were placed in the reference category. Such a method biases the

estimate towards the null. However, this practice also ensures that results are based

on the highest possible nurnber of respondents, and that information on the complete

variables is not lost. Non-responders who had to be exduded from the study because

they lacked information on mental distress, or in the subanalysis, occupation. were

evaluated to determine if they differed from responden with respect to the independent

variables and the two health outcomes (self-assessed global health and disability days)

for which complete information was available. If non-responders differed with respect to

both the independent and dependent variables, there would be a validity concem due

to selection bias.

3.5 STUDY POPULATION FOR T HESlS

A subsample of 91 1 women identified as not being bom in Canada who were of

typical working age (20-64 years old) was constnicted from the respondents to the in-

depth interview. Women lacking information on any of the three health outcome

measures being considered were excluded, leaving 859 women eligible for this study.

To examine associations between occupation and health, women who were currently

working in their main occupationS were identified (N=502). Those who did not disclose

their main occupation or who had information missing for any of the three

health outcornes were subsequentiy excluded, leaving 476 employed immigrant women

for the analysis.

3.6 DESCRIPTION OF VARIABLES

The original grouping by the NPHS of variables used in this study is found in

Appendix 3. Some of the original groupings were retained, while others were

collapsed. In some cases, several variables from the NPHS were combined to derive

specific variables of interest herein (Appendix 5).

Main Independent Variables

Employment Sta tus

The analysis of working-age immigrant women examined their health in relation

to their employment status as: full-time paid workers (30 hours per week or more); part-

time paid workers (less than 30 hours per week); or not in paid employment. A more

detailed distinction between women not in paid ernployment was precluded as too few

immigrant women of working age reported themselves as looking for work (N=lO) or

retired (N=48).

5. Instructions for coding the main job in the NPHS were as follows: "If the respondent is currentiy employed: encourage the respondent to pick the job they consider to be the main job; if the respondent absolutely cannot pick one, you should select the cuvent job with the most hours. If the respondent is not wrrently employed; encourage the respondent to pick the past job they considered to be their main job; if the respondent absolutely cannot pick one, you should select the past job with the longest duration in days." [68]

Occupation

In the subanalysis of women currently working for pay in their main job, the

variable of primary interest was occupation. In the NPHS, women who worked in the

year prior to the survey had their main job classified into socioeconomic occupation

codes, yielding sixteen possible levels within the job hierarchy. However, in this study,

only a very crude division was possible due to sample size constraints. Thus, women

were dichotornized into manual and non-manual occupations.

Potential Confounders or Effect Modifiers

Based on the literature review, selected variables thought to be meaningful in the

associations between work status or occupation and health in immigrant wornen were

examined for their possible roles as confounders or effect modifiers. Those included are

noted below.

Age

Because of the strong relationship between age and health, age was adjusted

for in the multivariate models. The original NPHS groupings were collapsed to create

the following groups by decade of life: 20-29,30-39,40-49, and 50-64 year olds.

Socioeconomic Characteristics

lncome adequacy and education were considered in the analysis so the

independent contribution of employment status or occupation to health could be

assessed separately from the health benefits associated with these related

socioeconomic factors. lncome adequacy, the measure used in this study when

controlling for the association of income with health, was based on the household

income in relation to its size and was classified into three groups: lowest, middle and

highest. The NPHS derivation of household income adequacy is found in Appendix 4.

a Although income adequacy was the independent variable with the highest proportion of

non-response (5%) in this study, this was still lower than what is typical for health

surveys [47. Those missing information on this and other covariates, were placed into

the reference category of highest income, so that the direction of bias would be towards

the null. This practice was found to be justified when cross-tabulation with another

variable, housing tenure, showed that non-responders were most like higher income

earners with respect to this variable. Arnong the non-responders, 76.2% lived in a

home owned by a family mernber; arnong the two highest income adequacy groups

75.6% and 88.0% lived in a house owned by a family member. By contrast, the lowest

income adequacy groups had family ownership below 35%. Therefore, non-responders

appear to be very much like the high income adequacy groups.

Educational requinments are also related to employment status and the type of

occupation a person rnay have and are independently related to health [3,49, 501.

Thus education, as income, was treated in this study as a potential confounder of the

association between work and health, with the twelve categories of educational

attainment in the NPHS collapsed into five: less than secondary school, secondary

school graduation, some pst-secondary, collegeltrade school graduation and

university graduation.

Social Roles

A woman's social rotes beyond that of paid worker may confound or modify work-

health associations. In this study, a woman's marital role and her responsibilities

caring for her family were considered as potential effect modifiers and confounders. To

this end, marital status was divided into three categories: never mamed (single),

currently married (including living with a partner and common law unions) and

0 previously married (widowed, divorced or separated), retaining the original NPHS

categories. Caregiver status was based on what a wornan reported as her current main

activity. Those who stated that they cared for their family, or combined caring for family

with other activities, were classified as caregivers. Those reporting their main activity to

be looking for work, working, going to school, being retired, recovering from illness/on

disabiiity or other, with no self-report of family care, were classified as not being

caregivers.

Ethnicity

Although the literature has identified broad ethnicity classifications as

problematic, the reliance of this study on previously collected data precluded definitions

of ethnicity other than country of birth. Moreover, because Statistics Canada had

already collapsed categories, only their four broad groups of foreign-born could be

used: Asia. U.S.NMexico, South AmericdAfrica and Europe. The limitations and

benefits of this approach are addressed in the discussion.

T h e Since immigration

The NPHS coded the length of time spent in Canada since immigration into three

broad categories: less than or equal to four years; five to nine years; and ten or more

years, and this original categorization was retained.

Health Selecüon

In examining associations between employment status and health, one may find

poorer health in those who are not in paid employment either because they have been

selected out of ernployment or their poor health has prevented them from entering into

employment. Thus, poor health may be an antecedent, not a consequence, of a

woman's employment status. Since this study is cross-sectional, the temporal

e sequence of any association between work and healai cannot be determined. To

crudely control for selection processes that may cause a "healthy worker effectl' in this

study, restriction of activity, dichotomized as yeslno by Statistics Canada, was used as

a control variable. A restriction of activity refers to "any long-tenn activity limitation,

disability or handicap that has lasted or is expected to last at least six months, resulüng

from a physical or mental condition or health problem" [70]. Restrictions of activity

measure the impact of disease or impairment on the functional ability of the individual in

normal life [ I O , 261. Women with restrictions of activity may be selected out of

employment, or they may experience difficulties entering paid employment. Thus. in

assessing the association between paid work and health, controlling for restrictions of

activity will remove, albeit crudely, selection effects.

Derived Variables

While most variables used in the analysis were already coded in the NPHS and,

at the most, only required categories to be wllapsed to yield reasonable sample sites

or more logical cutoffs, work status had to be derived from a number of other variables

in the NPHS.

Work Stafus Variable

Work status categories were created by combining information about the work

status of the respondent and the working hours pattern based on al1 jobs reported. A

flowchart of the classification scheme is found in Appendix 6.

Of the 502 women currently in paid employment, 353 were dassified as full-time

and 149 as part-time by this scheme. Cross-tabulations using other variables from the

NPHS to examine some characteristics of the different work status groupings revealed

that most of the women classified as currentiy working full-time had been working

a continuously for the previous 12 months. The mean duration of continuous work in this

group was 11.3 months (s.d.=2.5). Fewer than 10% had not worked continuously

throughout the entire year.

Among the women classified as working part-time, the majority had also been

working continuously for the past 12 months. The mean duration of continuous work

was 10.6 rnonths (s.d.=3.2), and fewer than one fourth had been working fewer than 12

months continuously.

Of the 357 women who were not currently employed, 70 had worked in the

previous year. Among this group, the main reason for not working was said to be layoff

(36%) followed by family and other reasons (both 21 %). This differed from the overall

distribution of wornen not in paid employment for whom the main reason for not working

was family responsibilities (43%). Unfortunately, too few observations occurred in the

su bgroups to permit their separate analysis.

Caregiving Variable

Although the caregiving variable was created simply by collapsing categories of

an existing NPHS variable, it was still cross-tabulated with other variables not used in

the analysis to see how it correlated with dimensions thought to be important to the

concept of caregiving.

Initially, rather than care-giving responsibilities, the impact of having dependent

children on the associations between work and health was to be considered. However,

the dependent children variable had certain limitations: a large portion of the women

were not classifiable as having or not having dependent children, especially those living

in extended families; the number of children was not known, only their ages; and how

much help the woman had with childcare was also not known. For these reasons, an

a alternative measure of unpaid domestic workload was sought.

The caregiver variable is preferable to the dependent children variable because it

conveys the wornan's self-rated perception of her carhg responsibilities. It likely

masures more than just the presence of children. For example, it may be sensitive to

the sharing of domestic labour, especially among women who work full-time in the paid

labour force, or it may account for a wider variety of care-giving responsibilities, such as

caring for husbands or elderly parents.

When the caregiving variable was cross tabulated with the variable indicating the

presence or absence of children. only 22.9% of women without dependent children

reported that their main activity was caring for family. By contrast, 79.2% of those with

dependent children (under twenty-five years old) indicated likewise. The caregiving

variable was also sensitive to the ages of a woman's children, with 87.5% of women

with children under five reporting caring for farnily, while 76.0% and 71.3% reported

likewise among women with children six to eleven and twelve to twenty-five

respectively. Marital status was similarly reflected, with many married women (65%)

reporting caring for their families, while only 37.4% of widowed, divorced, or separated

women and 13.7% of never married women indicated the same. Finally, women with

children who worked full-time still frequently indicated that their main activity included

caring for family. Among women with children under the age of five, 81.2% of those

working full-time also reported that their main acüvity included caring for their family,

while 93.3% of those worùing part-üme and 93.8% of those not in paid work indicated

likewise. Among women with children under the age of twelve, 72.6% of full-time

worken reported family care responsibilities, while 95.4% and 95.2% of part-timen and

non-workers reported the same.

Dependent Variables

This study examined three outcome measures which represent different, but

overlapping, dimensions of health: disability days in the previous two weeks, self-

assessed global health, and mental distress.

The derived number of disability days was the sum of the number of days spent

in bed and days where the respondent cut down on usual activities due to illness or

injury in the previous two-week period. It does not necessatily distinguish physical from

mental illness. Although responses could range from O to 14 days, the skewness of this

variable (median=3) justified its dichotomization into those reporting no disability days

and those with at least one,

Self-assessed health is a subjective measure which may be associated with

different expectations of health, different willingness to report the level of health, and

different ideas of what normal activities are. Despite this, it is a useful measure of the

experience of health and illness in the lives of the respondents [21]. Respondents were

asked to rate their current health on a scale ranging from "poot' (O) to "excellent"(5),

with this adjusted for whether they were pregnant at the time of reporting. Immigrant

women were dichotomized as having good or better health (2-4) vs not (0,l).

The mental distress index was based on a subset of items, predetermined by

Statistics Canada, from the Composite International Diagnostic Interview (CIDI). The

CIDI is designed to produce diagnoses according to the definitions and critena of both

the DSM-III-R and the Diagnostic Criteria for Research of the ICD-10. Although I could

not find any test of the cross-cultural validity of the particular subset of questions used

for the distress scale, the CIDI has been well studied cross-culturally at many different

test sites and has been shown to be well-accepted and reliable [88]. The distress index

a was based on responses to six questions (Appendix 2). with response options: al1 of

the tirne, most of the time, some of the time, a little of the time, and none of the time,

given weights 5, 4, 3, 2, and 1 respectively. Only the composite index, the sum of the

assigned weights for the six questions, was reported in the NPHS files for public use.

Possible scores ranged from 0-24 and were treated as a continuous variable, with

higher scores indicating more distress 1701.

3.7 STATISTICAL METHODS

All statistical analyses in this study were perfonned using SAS [60]. Initial

exploratory analysis used simple cross tabulations between the three health outcornes

and the different independent variables. Tests for association were done between the

independent and dependent variables, and between the independent variables

considered as covariates and the main deteminant of interest, work status. Extended

Mantel-Haenszel statistics were used to examine the nuIl hypothesis of no association

versus the alternative of either a difference in the row mean scores or a linear

association, depending on whether the independent variable was nominally scaled

(e.g., country of birth) or ordinally scaled (e.g., education) respectively. When ordinally

scaled covariates were examined in association with work status, standard ized

midranks6, rather than integers were used, since the categories of work status are not

equally spaced, although they were considered to be ordered by the degree of

involvement in paid ernployment from none to full-time.

Guided by the tabular analyses, each of the three health outcornes was

modeled separately using linear or logistic regression for continuous and dichotomous

6. Standaidized midrank score [60] defined as: a&&ra~;+ l 2(n+I )

a outcome variables, respectively, to examine the health associations according to work

status (main analysis) and occupation (sub-analysis), first considering interaction, and

then controlling for potential confounders. The assessment of confounding did not

employ statistical testing, since confounding is a validity issue and as such is related to

systematic, not random error [42]. Self-assessed global health, disability days in the

previous two weeks and mental distress were the dependent variables, while work

status was the main independent variable; age, household income adequacy, highest

education attained, marital status, caregiver status, country of birth, time since

immigration and restrictions of activity were the control variables. In the subanalysis of

women currently in paid employment, the main independent variable was occupation,

while the dependent variables and control variables remained the same.

The 95% Wald confidence intervals for the prevalence odds ratios were obtained

from the multiple logistic regressions. The Wald test is a z-test, so the test statistic is

approximately standard normal. This method yields similar results to other methods,

such as the likelihood ratio method when the sample site is large [42], and it is readily

obtainable from the standard SAS printout. Confidence intervals for coefficients

involving interaction terms were rnodified to incorporate both the variances and the

covariances of the estimated coefficients [42].

The final models were examined for influential observations and undennlent

testing for goodness of fit. Residual analysis was done to identify observations or

covariate patterns poorly explained by the model and to determine whether the

assumptions of regression held. Goodness of fit was assessed based on the deviance.

If the deviance chi-square value yielded a non-significant p-value, the model was

judged to fit to the data well as the test did not refute the nuil hypothesis that the mode1

fits the data perfectly with discrepancies due to random error only.

4 RESULTS OF ANALYSIS OF WORK STATUS-HEALTH ASSOCIATION

4.1 DESCRIPTION OF STUDY POPULATION

The distribution of study subjeds among categories of the independent and

dependent variables was examined (Table +-Tables begin on page 77).

Most of the 859 working-aged immigrant women described their health as good

or better (88%), and few had experienced any disability days in the previous two weeks

(1 8%). The continuous outcome variable, mental distress, showed women generally

had low distress levels (mean=3.85, s.d.=3.69). Its distribution was skewed. However,

because skewneçs is a concem with respect to the conditional, not the marginal

distribution, transformation was not planned unless supported by the conditional

distribution for the final multivariate modei.

Almost equal numbers of women were either working full-time or not in paid

employment with about 40% of the respondents in each group. Fewer than 20% of

women were working part-time. They were approximately equally found in the different

categories of age, with slightly more either in their thirties, or behnreen fifty and sixty-

four. With respect to the socioeconornic variables of income and education, the study

population mostly fell into the high income adequacy group (50%) with a sizable portion

in the low income adequacy group (23%). Approximately equal numbers were in the

two lowest and two highest categories of ducational attainment, with the central

category of women with some post-secondary education having the largest portion of

women (28%). Approximately half the women reported having care-giving

responsibilities, while the other half did not. Most were mamed (65%), with the

remaining women equally likely to be previously or never married.

a Women were unequally distributed by country of birth and time since

immigration. Most women were born in Europe (53%) and were long-term immigrants

(75%). Recent immigrants made up only 11 % of the women studied, while 14%

imrnigrated between five and nine years ago. Only 11 % were bom in the U.S.A. or

Mexico, and few were born in South Arnerica or Afnca (1 4%). A sizable portion (22%) of

the women were born in Asian countries.

A relatively large portion of women in this study population reported activity

restrictions (7 9%). Thus. one Mai had functional limitations in their health, which,

among other things, may have reduced their ability to participate in the workforce.

4.2 PRELIMINARY ANALYSES

Bivariate Associations

Simple statistics were calculated to examine the variables to be treated as

confounders of the association between work and health. To confound an association,

a variable muçt be an extraneous deteninant of the outcome (self-assessed health,

mental distress, disability days), and be differentially distributed across the categories of

the exposure of interest (full-time, part-tirne, not in paid employment). These criteria

are examined in Table 2. Table 3 and Table 4.

Associafion Between Wwk Status, Potential Confounders and Health

Table 2 examines which variables were associated with health. Tests for

association or trend were done in each case and those significant at the p=0.05 level

were noted. However, it should again be emphasized that assessrnent of confounding

will not employ statistical testing. The tests were done to also consider the variables'

independent association with health. Unadjusted measures of effect (odds ratio or

esürnated mean difference in distress) and their 95% confidence intervals for the

associations between work status (full-time, part-time, vs not in paid employrnent) or the

potential confounders and the three health outcomes (self-assessed health, disability

days, and mental distress) were also estimated using simple linear or logistic regression

(Table 5). The results mirror those of Table 2 and will not be repeated.

The main variable of interest, work status, was associated with self-assessed

health and disability days. Full-time and part-time employees reported poor self-

assessed health less frequently than those not in paid employment. Similarly, both full-

time and part-time workers reported disability days less often than those not in paid

employment. For mental distress, women in paid work, whether full- or part-time had

lower mean distress levels than women without paid work, but the association was not

statistically significant.

Older women reported poorer self-assessed health and more disability days than

younger women, although the trend was only statistically significant for self-assessed

health. By contrast, mental distress scores had a downward trend with increasing age.

Thus, older women reported lower mean levels of distress.

Average mental distress scores were lower in married women than previously or

never married women, but showed no significant associations with the other two

outcomes. Similarly, women classified as care-givers also reported significantly lower

levels of distress and better self-assessed health, but did not differ from women who

did not care for a family for disability days.

Educational attainment was associated with self-assessed health with women in

the lowest educational attainment categories reporthg the lowest level of health, and

those in the highest categories reporting the highest level. This trend was not seen for

disability days or mental distress; both showed high levels among the middle category

of women with some post-secondary schooling as well as among those who had not

completed highschool. Low income adequacy was associated with poorer health,

regardless of the healh outcome.

Immigrants of intermediate (5-9 years) length of stay had better self-assessed

health than long-term immigrants, but recent immigrants did not show a significant

difference. Similar patterns were evident for disability days. though none of the

associations were statistically significant. Again, immigrants with intermediate lengths

of stay reported the smallest proportion with one or more disability days. Length of stay

was not significantly associated with distress. Regardless of the health outcome

examined, associations behnreen country of birth and health were not statistically

significant.

As one would expect, having a restriction of activity was strongly associated with

having disability days, poor self-assessed health and higher mental distress levels.

Association of Potential Confounders with Work Status

Some of the potential confounders were associated with work status (Table 3).

Patterns of labour force participation differed according to age, caregiver status, income

adequacy, educational attainment and restrictions of activity.

Women responsible for caring for their families comprised a smaller portion full-

time workers, in contrast to those not responsible for caring for their families, who were

most likely to be full-time workers.

Immigrant women's work status also differed according to their educational

attainment and household income adequacy. Those with a highschool diploma or less

comprised a larger portion of the not in paid employment group, while those with some

education past highschool represented a larger portion of the part-time workers.

Women with college, trade school or university diplomas fonned a greater proportion of

the full-time workers. Finally, women with household incomes of low adequacy were

less likely to be employed. By contrast, those with medium income adequacy

constituted equal portions of al1 work status groups, while women with high household

incorne adequacy were most often in the full-tirne category.

A large portion of women with restrictions of activities were not in paid

employ ment, while those without activity restrictions formed a greater portion of paid

workers (full- and part-time). Thus restrictions of activity were strongly associated with

work status.

The remaining variables marital status, tirne since immigration and country of

birth were not associated with work status.

Co varia tes Meeting BOU, Criteria for Con founding

Table 4 summarizes Tables 2 and 3 to show which covariates met both criteria

for wnfounding the work-health association. lncome adequacy and restrictions of

activity consistently met these criteria for al1 three outcome variables. Age and caregiver

status were both associated with work status and two outcomes (self-assessed health

and mental distress), while education only met both criteria for self-assessed health.

Time since immigration, country of birth, and marital status, while associated with health

outcornes in some cases, al1 lacked an association with work status and therefore did

not meet the criterion of differential distribution across the main determinant of interest.

Nonetheless, they were independently associated with some of the health outcomes.

Stratified Analysis: Confounden of the AssociaHon Between Worlc and Health

Having considered which of the covariates met criteria to be confounders of the

work-health association, regression analysis was carried out to assess confounding of

O the association between work status and health (Table 6). A covariate was considered

to be a potential confounder if the parameter estimate for the association between work

status and health changed 10% or more upon its addition to the model. Actual

confounder status will be considered in a full model which sirnultaneously examines al1

the covariates of interest. Statistical signifieance was not taken into account in the

assessrnent of confounding, since confounding is a matter of systematic bias, not

random error, as accounted for by statistical testing [42].

An examination of changes in the parameters for full-time and part-time paid

work indicated that age reduced the strength of the association between work and self-

assessed health and increased the strength of the association with mental distress, but

did not confound the association with disability days. Time since immigration and

country of birth altered the parameter estimate for the association between full-time

work and mental distress. but did not affect the association between work and the other

two health outcornes.. Education and caregiver status confounded the association

between full-time work and self-assessed health and mental distress, but not disability

days, while income weakened the association of work with disability days and distress,

but not self-assessed health. Marital status did not alter the parameter estimates for

any work-health associations. The only variable that weakened the association between

work and health regardless of the dimension of health considered was restrictions of

activity, the variable included in the analysis to control for health selection processes in

the labour market. Many of these results mirror those in Table 4. Differences occurred

since alteration in the parameter estimate for either full-time or part-üme work's

association with the outcome was taken as evidence for confounding here, while when

observing trends, an association across al1 categories of work status was required.

Tri- and Multivariate Analyses- Effect Modifiers of Work-Health Associations

When effect modification is present, reporting a single sumrnary value for the

association of interest is misleading. Additionally, consideration of interaction rnay

indicate additional variables to be controlled or rnay eliminate the need to consider

confounding, except within specific levels of modifiers. Thus, based on studies which

suggested that women's paid and unpaid work may interact to alter the association with

health, an e prion interaction was considered (Table 7). Since interaction is model

dependent [41], 1 should be noted that for the continuous outcome variable, mental

distress, which was modeled using multiple Iinear regression, tests for statistical

interaction look for departures from additivity, while for the logistic models, deviations

from a multiplicative no interaction state are tested [41].

Among women who reported that their main activity included caring for their

family, neither full-time nor part-time work was associated with better health as the odds

ratios consistently included the null. Investigation of potential confounders indicated that

regardless of which covariate was considered, this finding remained the same. By

wntrast. a protective association between both full-time and part-ürne work, and health

was found among women who reported not being responsible for caring for their family

as a main activity. Irrespective of the measure of health, they had better self-assessed

health, fewer disability days and lower distress levels. However, the associations were

affected by the control of confounders. For self-assessed health, the association with

work was weakened upon addition of education and of restrictions of activity, though in

both cases work remained significantly protectively associated. For disability days, the

association was also weakened upon addition of restrictions of activity to the model,

such that it was no longer significant. Finally, for mental distress, addition of restrictions

of activity, marital status, incorne education and country of birth al1 resulted in a

reduction in the estimated mean difference in distress to the extent that work was also

no longer significantly associated with distress. On the other hand, the association

between work and mental distress was strengthened upon addition of age. This

suggests the need to consider the potential confounders in a multivariate model; some

will be redundant, while others which do not confound the association when considered

alone, may do so when combined with others.

4.3 MULTIPLE LINEAR AND MULTIPLE LOGISTIC REGRESSION

Guided by the preliminary analyses, multiple linear and multiple logistic

regressions were used to amve at a best model for the association between work and

the three health outcomes in immigrant women. First, a full model was examined,

containing the interaction between paid work and caregiving responsibilities, as well as

al1 the covariates, whether potential or actual confounders. Retention of the interaction

term was based on statistical grounds. If it was found to be significant at the p=0.05

level, it was retained in the rodel, along with its lower order components. Retention of

confounders was not based on statistical grounds. Rather, several more parsimonious

models containing a subset of the initial potential confounders were considered. If a

subset of variables controlled for bias equally well, meaning the parameter estimates for

work status, the interaction between work and caregiving, and caregiving were not

substantially altered compared ta the full model, then the more parsirnonious subgroup

was selected, provided 1 yielded a more precise estimate as well. Finally, although not

the primary objective, covariates not included as confounders were eligible to be tested

to detemine their independent association with health in immigrant women. Eligible

covariates were first tested as a group, and if the group was found significant, they

0 were tested individually to detenine which variables in paiticular were significantly

associated, with p=0.05 as a criterion for retention in the model. Results for the various

steps taken to arrive at final models are found in Appendix 7.

For the multiple regressions, the distinction between full-time and part-time work

could no longer be rnaintained as colinearity problems arose once multiple covariates

were considered: the small number of women working part-üme among women not

caring for family led to an unstable parameter estimate for part-time work. Thus full-time

and part-time work were combined into a single category. This decision was further

justified by the preliminary analyses which indicated that the parameter estimates and

particularîy their confidence intervals for the associations between full-time and part-

time work and health were quite similar.

Self-Assessed Heafth

In the full model for self-assessed health (Appendix 7), the interaction between

caregiver status and work status was highly significant. Therefore, it was retained. A

comparison of the odds ratios for the V ~ ~ O U S combinations of work status and

caregiving controlling for al1 confounders was made. When various more parsimonious

models were examined, in most cases either the parameter estimates changed

meaningfully (2 10%) from those in the full rnodel. or they did not yield any greater

precision. However, one more parsimonious model gave very similar parameter

estimates and narrower confidence intervals. This model excluded age, marital status

and income adequacy. A chunk test for the significance of these vanables did not yield

a significant result. Therefore they were not included as factors independently

associated with health in the final model. The final model is found in Table 9, and the

parameter estimates for the various categories of worù status and caregiving can be

seen in Table 9b.

Table 9b indicates that compared to the reference group of women who neither

care for a family nor participate in paid employment, al1 other combinations of paid work

and caregiving are protectively associated with self-assessed health. Women who work

for pay but do not also have family care responsibilities have the strongest protective

association. They are almost five times less likel y to report poor self-assessed health

than the reference group. Women who combine caring for family with paid work show

the weakest protective association, but they are still two times less likely than the

reference group to report poor self-assessed health. Caring for family in the absence of

paid work was also associated with better self-assessed health in immigrant women.

with these women less than half as likely to report poor self-assessed health than the

reference group.

Although not the primary objective of this analysis, the strength and direction of

the associations between the other variables retained in the mode1 and self-assessed

health could be examined. The odds of reporting poor self-assessed health decreased

with increasing education. with more educated women reporting better self-assessed

health. Compared to the reference group of long-term immigrants, medium term

immigrants also had better self-assessed health, though recent immigrants (those who

immigrated 0-4 years previously) did not display any advantage. Not surprisingly.

women who reported restrictions of activity reported substantially poorer health. They

were neariy 12 tirnes more likely to report paor self-assessed health compared to

women who did not report restrictions. Country of birth, was also associated with self-

assessed health, thoug h no associations were significant at the p=0.05 level.

Nonethsless, compared to European immigrants. immigrants from Asia and South

a Arnerica or Africa reported nearly twice the level of poor self-assessed health.

Immigrants frorn the USA or Mexico did not differ substantially from European

immigrants.

Disability Days

In full model for the association between work status and disability days the

interaction between caregiving and paid work was not statistically significant (Appendix

7, Table Bi). Therefore, it was not retained on statistical grounds. However, a

cornparison of the parameter estimates for the various combinations of paid work and

caregiving was still tabulated (Appendix 7, Table 82) to see how they differ from those

found for self-assessed health (where a significant interaction was found). The

parameter estimates show a similar pattern to those for self-assessed health, with the

strongest protective association among women solely participating in paid work

compared to the reference group of women with no caregiving or paid work activities.

Yet, even here, the prevalence odds ratio confidence interval estimate includes the nuIl

(O.R.=0.67, 95% C.I.=0.38-1.19). Again, when paid work is combined with caregiving,

the protective association is weakest. It must, however, be emphasized that the

presence of interaction was rejected on statistical grounds, and none of the

associations found is statistically significant. Consideration of the pracücal significance

of these observations is left to the discussion.

A full rnodel without interaction ternis was examined, and the adjusted odds ratio

for the association between paid work and disability days showed no evidence for

rejection of the nuIl hypothesis of no association. The odds ratio of having one or more

disability days in the previous two weeks in paid workers compared to those not in paid

employment was esümated as O.R.=0.86,95% C.I.=0.58-1.30. Controlling for various

coml

they

with

selec

conti

asso

asso

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paral

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binations of covariates did not yield substantially more precise estimates, nor did

greatly change the parameter estirnate. Paid employrnent was still not associated

disability days, and the odds ratio remained virtually unchanged. The final model

:ted is found in Table 9. The preliminary analyses had already indicated that

roi for either income adequacy, or for health selection removed the protective

iciation between work status and disability days (Table 6). Thus the protective

iciation between paid work and disability days seen in the simple bivariate case is

r explained by the higher income adequacy of wornen participating in paid

loyment or by the selection of healthier women into employment.

ta1 Distress

In the full model for the association between work status and mental distress, as

isability days. the interaction term between caregiving and paid work was not

;tical!y significant (Appendix 7, Table C l ) and was removed. Again, however the

meter estimates for the possible combinations of paid work and caregiving were

~ared. As with disability days, the parameter estimate for the mean difference in

sss for women caring for their families and participating in paid work as cornpared

e reference group of women who do neither was in a protective direction. The

ition of the estimates for women solely caring for family or solely in paid work were

in a protective direction. However, unlike for disability days and self-assessed

:h, the strongest protective association was seen in women who solely care for

y (P=-0.61, 95% C.I.=1.43,0.21). Again, it must be emphasized that none of the

ciations were statistically significant.

When a full model without interaction ternis was examined, the adjusted

meter estimate for the association between paid work and mental distress was not

significantly different from zero. Regardless of which covariates were controlled, the

lack of association between work status and mental distress rernained. Since few

rnodels yielded substantially different estimates from the full model, the most

parsimonious model which included work status along with other predictors of mental

distress in immigrant women was chosen as the final model (Table 11). This model

showed little support for an association between work status and mental distress. On

the other hand, increasing age and income adequacy were protectively associated with

distress. Previously married women also had significantly higher mean distress scores

than married women and never married women also had higher distress scores, but not

significantly so.

5 RESULTS OF SUB-ANALYSIS OF ASSOCIATION BETWEEN MANUAL OCCUPATION AND HEALTH

A subanalysis of immigrant women currently working in their main job was done

to examine how their position in the labour market was associated with health by

comparing manual workers to non-manual workers. After excluding women for whom

mental distress scores and current main job were not available, a total of 476 women

currently employed in their main job were available for analysis.

5.1 DESCRIPTION OF STUOY POPULATION FOR SUBANALYSIS

Most wornen in this study population described their health as good or better

(93%), and only 15% had one or more disability days in the previous two weeks (Table

il). These women had low levels of distress, with a mean of 3.65 and scores ranging

from 0-1 8. Approximately 16% were working in manual occupations. One fourth of the

women were working part-time. while three quarters were full-time employees. About

half of the women were over forty, and the rnajonty (66%) were mamed. Again. alrnost

half (46%) described a main activity which induded caring for family. Most women

70

a were in the highest category of income adequacy (60%). but despite being currently

ernployed, 14% were still in the lowest categones of income adequacy. Over 40% of

the women studied had a post-secondary degree or diplorna. Few women had

immigrated in the past ten years (20%), and most were bom in European countries

(55%), with the next largest group being born in Asia (19%). A few women, despite

being ernployed, reported restrictions of activity (1 1.3%). though in this case, since they

were currently working, the restriction could not have been a banier to their participation

in the labour force.

5.2 PRELIMINARY ANALYSES

Bivariate Associations

Bivariate associations were examined to determine whether the covariates were

associated with both health and the main variable of interest, which was working in a

manual occupation as compared with other occupations.

Associaifon Between Occupation, Potential Confounders and Healfh

Working in a manual occupation, with reference to other occupations, was

associated with poorer self-assessed health and higher levels of distress (Tables 13 &

14). Manual occupations showed no association with disability days (0.R.z 1 .O).

Several potential confounders were also associated with health. Being older was again

associated with poorer self-assessed health, but lower levels of mental distress.

Women with restrictions of activity more offen reported poor self-assessed health and

having one or more disability day, but interestingly no difference was seen for mental

distress. Higher househoid income adequacy, was significantly associated only with

lower mental distress, while higher educational attainment was associated only with

a better self-assessed health. Never marrîed women showed higher levels of mental

distress than women who were not, but marital status was not significantly associated

with the other two health outcomes. Country of birth, time since immigration, caregiver

status and working full-time relative to working part-tirne show no association with any

of the health outcomes.

Association of Potential Confounders wiUl Occupation

Only income. education and country of birth were significantly associated with

work in a manual occupation (Table 12). Women with higher income adequacy and

education were less likely to be working in manual occupations. In fact, only one

woman with a university degree was working in a manual occupation. Women born in

South America, Africa or Asia were also more likely to be rnanual workers.

Potentiel Confounders Meeting Both Critefia for Confoundhg Variable

Only educational attainrnent and income adequacy were associated with working

in a manual occupation and with at least some of the health outcomes. Educational

attainment met both criteria for a confounder of the association between working in a

manual occupation and self-assessed health, while income adequacy met both criteria

when distress was the health outcome of interest.

Stratified Analysis: Confounders of the Occupation-Health Association

The associations between working in a manual occupation and the three health

outcomes were examined upon addition of the covariates considered to be potential

confounders (Table 15). Although evaluation of interaction would have been of interest.

sample size constraints made it infeasible.

For self-assessed health, only educational attainment, income adequacy and

restrictions of acüvity altered the odds ratio for the association behnreen manual

0 occupations and health. lncluding education reduced the odds ratio; therefore. some of

the poor health associated with working in a manual occupation was related to the

lower level of education of women working in these positions. There was an increase in

the odds ratio upon the addition of restrictions of activity possibly due to the better

health required to perfom manual occupations. Women with restrictions of activity rnay

be selected out of rnanual occupations while they may be able to continue working in

non-manual occupations. An increase in the odds ratio for the association between

working in a manual occupation and self-assessed health upon control for income

adequacy was not easily explained. It is possible that in a multivariate regression that

includes other confounding variables, the direction of the association will become more

clear.

When considering the association between having any disability days and

working in a rnanual occupation, only educational attainment and caregiving activities

altered the odds ratio. However, in bath cases, the association between working in a

manual occupation and health remained statistically non-significant.

When examining the change in the association between mental distress and

working in a manual occupation upon addition of othei independent variables,

educational attainment, income adequacy, work status and restrictions of activity

slightly altered the strength of the association. Both the lower educational attainment

and lower incomeç found in manual workers accounted for some of their higher

distress. The smaller proportion of full-time worken and women with restrictions of

activity in manual work reduced its association with mental distress.

5.3 MULTIPLE LINEAR AND MULTIPLE LOGISTIC REGRESSION

Autornated model selection procedures were employed to select which variables

should appear in the final mode1 (Table 16). This was done because the preliminary

analyses for disability days in parlicular cast doubt that working in a manual occupation

was at al1 associated with this health outcome. Forward, backward and all-subsets

selection were performed selecting from the entire pool of independent variables. A

loose significance level for entry and staying in the model of a=0.25 was chosen. All

subsets selection was based on the adjusted R-squared for the Iinear regression or on

the score statistic for logistic regression.

Self-Assessed Health

Identical rnodels were selected using foward, backward and all-subsets

regression for self-assessed health. Manual work, age, time since immigration, country

of birth, educational attainment, income adequacy, caregiving responsibilities and

restrictions of activity were al1 included in the final model. Some of these variables were

independently associated with self-assessed health. while others were previously seen

to confound the association between working in a manual occupation and having

poorer self-assessed health in Table 15.

Disability Days

Occupational status was not selected as a variable associated with disability

days; the odds ratio for the association was always around 1 .O. All three selection

procedures included age, income adequacy and restrictions of activity in the model.

The all-subsets regression also included caregiving as an important predictor.

Mental Distress

Identical models were selected using forward, backward and all-subsets

regression for self-assessed health. Manual work, age, time since immigration. income

adequacy, and restrictions of activtty were al1 included in the final model. Again, some

of these variables confounded the association between working in a manual

occupation and distress, while others were independently associated with distress.

5.4 FINAL MODELS

Few of the associations in these final models were significant at the a=0.05

level. Nonetheless, findings will be reported. particularly for associations that have

relatively large measures of effect despite being non-significant (Table 1 7). Smaller

sample sizes for this sub-analysis may be problematic, especially since variables

relating to an individuals' social environment were being examined; associations with

such variables usually have smaller effect sizes which require larger sample sizes to

avoid Type II errors.

Working in a manual job was associated with poor self-assessed health

(O.R.=2.0,95% C.1 .=(O.ï,5.6)). Among women in paid employment, caring for family

was associated with poorer self-assessed health. The strength of this association was

of similar magnitude as working in a manual occupation (O.R.=2.2,95% C.I.=(I .O-5.0)).

Country of birth, was also associated with poor self-assessed health independently of

work status. In women in the paid labour force, being bom in an Asian country was

associated with poorer self-assessed health (O.R.=3.8, 95% C.I.=1.4-1 0.4)). as was

being born in South America or Afnca (0 .R~2 .5 , 95% C.l.=0.8-7.9)). Educational

attain ment was protectively associated wit h self-assessed health . while income

adequacy was controlled for validity purposes, to obtain a less biased estimate of the

independent contribution of occupational status. Restrictions of activity were strongly

associated with self-assessed health, and interestingly, addition of this variable

strengthened the association between manual work and poor self-assessed health.

Similar to what was seen for work status. disability days were also not

0 associated with working in a manual occupation compared to a non-manual occupation.

Only restrictions of activity were significantly associated with this outcorne.

For mental distress. working in a manual occupation was no longer significantly

associated with health once income adequacy was controlled for in the final model

(estimated P=0.7, 95% C.1.-0.1-1.6). Thus the negative association between working

in manual occupations and mental distress was largely explained by the lower incomes

of women in this category.

6 COMPARISON OF RESPONDENTS REMOVED FROM STUDY DUE TO MISSING INFORMATION WlTH THOSE REMAlNlNG IN STUDY

Women who were removed from the study were examined to assess whether

they differed from women who were included (Table 18). Evaluating the women who

were excluded from the study because they lacked information on mental distress,

showed that the excluded women were more likely to be married, and less likely to be

caring for their family. Those excluded were not different from the included women with

respect to income; However, those with less than a highschool education were far

more likely to be excluded, and the excluded women were more likely to be working full-

time. With respect to factors unique to immigrants, length of stay was associated w lh

being excluded due to partial non-response. Recent immigrants, and those who were

bom in Asia had a greater likelihood of missing infornation for mental distress. No

association behiveen the other two outcornes, self-assessed health and disabil ity da ys.

and partial non-response was evident. This relieved some of the concem that non-

response may be differential by demonstrating that non-response was mainly

associated with the independent variables, and was probably not associated with

health.

Table 1: Description of Study Population of 859 Immigrant Women of Working Age

1 Variable 1 Category 1 Frequency 1 Percent 1 Self-assessed I Poo rlfa ir 1 Health Good or better

1 Disability days None One or more

Mental distress I Continuous variable (Possible range 0-24)

Work status Full-time Part-time No paid work

Care-g iving Responsibilities

Marital status Mamed Never married Previously married 1 Restrictions of activity

Time since immigration 0-4 years 5-9 years 1 O+ years*

USNMexico S .Arnen'ca/Africa EuropetAustralia' Asia

Highest education attained - - -

Less than highschool* Highschool Some post-secondary College diploma University degree

Incorne adequacy Low income 193 Middle income 237 High income* 429

'=reference group. Respondenh missing information were placed in reference category

Table 2: Proportion of Subjects With Poor Self-Assessed Health, One or More Disability Day, and Mean Distress by Work Statuç or Level of Potential Confounder

Variable Level

Fu II-time Part-time No Paid Work

% With Poor Self-assessed

Health

% With r i Disa bility Day

20-29 years old 30-39 years old 40-49 years old 50-64 years old

Caregiver Not Caregiver

Married Never Married Previously Married

--

Mean Distress (S.D.)

lmmigrated04yearsago lmmigrated 5-9 years ago lmmigrated IO+ years ago

UsAlMexico Europe/Australia Asia S.America/Africa

Less than Highschool Hig hschool Some Post-secondary College Diplorna University Degree

Low Income Middle Incorne High lncome

Restriction No Restriction 1 =test for association significant with ps0.05

78

6.0 7.3

11.9 22.1 T

10.4 14.6 T

11 .? 9.4

17.8

14.5 18.0 20.4 19.7

18.3 18.5

18.7 17.3 18.4

10.3 3.4

14.4 T

7.4 13.7 10.2 15.1

19.9 13.7 12.1 9.6 7.4 T

17.1 13.5 9.8 7

41.5 5.6 T

- -

15.5 13.7 19.7

19.0 19.8 14.5 18.5

22.6 14.9 19.6 16.0 18.8

25.9 t 3.9 17.5 T

37.2 14.0 T

r r f a m g g %

- -

Less than highschool Highschool Some Post-secondary College Diploma University Degree T

Caregiver Not Caregiver T

Low tncome Middle Incorne High Incorne T

T =test for association significant with ps0.05

Table 4: Association of Potential Confounders with Work Status and Health Outcornes

Covariate

Incorne Adequacy

Associated with Self-assessed

Health

Educational Attainment

Associated with Disability

Days

1 Marital Status

Time since Immigration

Country of / Birth

Restriction of Activity

Associated with Mental

Distress

Associated with Work

Status

X i significant association found at the p=0.05 level

X X

Table 5: Measures of Association with Health from Simple Linear or Simple Logistic Regressions for Work Status, and Potential Confounders

Variable Category O.R. for Poor Self-assessed Health(95% C.I.)

-

Time since l mmigration

O.R. for > l Disability Oay (95% CI.)

-- -

Work Status

Ag8

1 O+ Years 5-9 Years 0-4 Years

No Paid Work Part-time Full-time

20-29 30-39 40-49 50-64

- -- -

Caregiver No

Country Of Birth

- -

EuropelAustralia Asia S. ArnericalAfrica USA/Mexiw

Reference 0.26 (O. V,O.55)* 0.31 (0.20,0.50)*

Reference 1.23 (0.55,2.75) 2.10 (0.98,4.50) 4.42 (2.18,8.96)*

1 Reference 0.66 (0.43,0.91)* 0.63 (0.39J . I l )

Reference 1.30 (0.75,2.25) 1.51 (0.88,2.62) 1.45 (0.85.2.47)

Reference 0.21 (0.08,0.58)' 0.68 (0.34J.36)

Reference 0.65 (O.37.I. 13) 0.75 (0.41 J.34)

Reference I Reference 0.68 (0.45,1 .OZ) 0.99 (0.70.1.40)

- - - - - - - -

Reference 0.72 (0.42J.23) 1.1 2 (0.64J.98) 0.50 (0.22,1.13)

-- --

Reference 0.69 (0.43.1.1 O) 0.92 (0.55.1 5 4 ) 0.95 (0.54J.66)

--

Estirnated Mean Difference in Distress (95% C. 1.)

Reference -0.39 (-0.92,O. 14) -0.36 (-1.1 O,O.38)

Reference -1 .O6 (-1.78,-0.32s -1 .O0 (-1.74,-0.26)' -1.68 (-2.41 ,-0.95)*

Reference 0.17 (-0.56,0.89) -0.1 8 (-0.96,0.60)

Reference -0.68 (-1.17,-0.19)* - -

Reference -0.14 (-0.77.0.49) 0.39 (-0.35,1.13) -0.40 (-1.22,0.42)

- - -

Ah

C V - . '

cl., ai- -?* O 0 Y

m a C9C9 O 0 -

n- o m u.),V! 0

QIN r

&4 F m C ? ! O 0

--

Gare For Family

- --

None Age

, Tirne Birth Country

1 Education Incorne Marital Status Activity Restriction

-

None Age Time Birth Country Education lncome Marital Status Activity Restriction

Pa rt-time

Model

Table 8a: Final Model for Work-Self-Assessed Health Association

Paid Work Careg iver Paid WorkeCaregiver lmrnigrated 0-4 Years Ag0 immigrated 5-9 Years Ag0 Asia S .AmericalAfrica USAIMexico Highschool Graduate Some Post-secondary Diploma College Diploma University Restriction of Activity

Paramete r Estimate

Odds Ratio

0.21 0.38 5.88 0.84 0.21 1.84 1.86 0.71 0.76 O .44 0.32 0.4 1

1 1.79

Deviance x2

Table 8b: Odds Ratios and 95% Confidence Intervals for Association Behveen Work and Self-Assessed Health by Level of Caregiver Status

- -

No Paid Work

- -

Care for Family 0.47 (0.24.0.92)

Don't Care for Family

0.21 (0.1 0,0.43) -

- - .. . . - -

1 .O0 (Reference)

Table 9: Final Model for Work-Disability Days Association

Model Parameter Estimate

paid work low income adequacy medium incorne adequacy restrictions of activity

Table 1 O: Final Model for Work-Mental Distress Association

Odds Ratio

Model

95% C.I.

-

paid work age 30-39 age 40-49 age 50-64 low income adequacy medium income adequacy never married previously married restrictions of activity

- -

Parameter Estimate

Deviance x2

Table 11 : Characteristics of the Study Population of Women Currently Working in Main Job (N=476)

1 Variable Name 1 Categories

self-assessed ( health

disability days in past 2 weeks 1 mental distress continuous

(possible range 0-24)

1 occupation I manual non-manual

main activity caring yes for family I no

marital status married never manied previously manied

time since immigration

country of birth USIMexico S.AmericalAfrica Asia Europe/Australia

- -

highest education attained

full-time 1 part-tirne

less than highschool highschool grad. some past highschool college diploma university diploma

household income adequacy

restriction of 1 activity

low medium high

Frequency 1 percent (

Table 12: Association of Potential Confounders with Occupation --

Potential Confounder

- - - --

Manual Occupation Level Non-Manual Occupation

- -

frequency 1 percent frequency percent - --

20-39 years 40-49 years 50-64 years

careg iver

marital status rnarried never rnamed previously married

time since immigration

0-9 years 210

country of birth USNMexico S .America/Africa Asia Europe/Australia T

-- -- - --

highest education attained

less than highschool hig hschool some past highschool college diploma university degree T

household income adequacy

low medium hig h T

work status

restriction of activity

T =test for association signifmnt with ps0.05

Table 13: Association of Manual Occupation and Potential Confounders with Health

Variable Level %Les than Good Self- Assessed

Health

%21 Disability Day

in Past 2 Weeks

Mean Distress

Level (SD)

occupation non-manual manual

marital status

manied never marn'ed previously rnamed

time since 0-9 years immigration 2 10

country of birth

UsAlMexico S. Arne rica/Africa Asia EuropeiAustralia

highest less than highschool 17.2 education highschool 7.0 attained some past highschool 4.5

collage diploma 6.1 university degree 5.0 T

household low incorne medium adequacy high

work status full-time part-üme

restriction yes ofactivity I no

association

Table 14: Measures of Association with Health from Simple Linear and Logistic Regressions for Occupation and Potential Confounders

Variable

Occupation I non-manual manual

20-39 years 40-49 years 50-64 years

- -

marital status mamed never mamed previously married

time since immigration

country of birth Europe USAfMexico S.America/Africa Asia

Odds Ratio Poor Self- Assessed

Health (95% CI)

Reference 2.5(1.2,5.4)

Reference 1.5(0.6,3.6) 2 4 1 .0.5.1 )

-

Reference O.5(O. 1J.6) O.i(O.3,1.9)

Reference 1.8(0.6.5.3)

Reference 1.3(0.4,4.2) 1.7(0.7,4.7) 1.9(0.8,4.6)

Odds Ratio for 2 1 Disability

Days(95% CI)

Reference 1.0(0.5,1.9)

Reference 1.6(0.9,2.8) 0.7(0.4,1.5)

-

Reference 1.6(0.9,2.8) 0.7(0.4,1.5)

Reference 1.3(0.6,2.4)

Reference 1.0(0.5,2.2) 0.8(0.4,1.8) 0.9(0.5,1.8)

Estirnated Mean Difference in

Distress (95% CI)

Reference 0.8(0.0,1.7)

Reference -0.5(-1.3,0.3) -1.1 (-1.9,1).3)

Reference 1.0(0.2,1.8) 0.4(-0.4,l.Z)

Reference -0.1 (-0.9,0.7)

Reference -0.1(-0.9,0.7) +O.4(-0.6,I .4) -0.2(-1.0,0.6)

Table 15: Association between Health Outcome and Working in Manual Occupation Upon Control of Potential Confounders

--

Control Variable

marital status

time since immigration -

country of birth

highest education attained

main activity caring for family

household income adequacy

work status - -

restriction of activity

- -

Poor Self- 2 1 Disability Day Estimated Mean Assessed health O.R. (95% C.I.) Difference in O.R. (95% C.I.) Distress (95% C.I.)

2.5(1.2-5.4) l.O(O.5-1.9) 0.8(0.0,1.6)

Table 16: Results of Automated Selection Procedures for Mental Distress, Disability Days and Self-Assessed Health

Variable Mental Distress Model

Disability Days Model

- -

Self-Assessed Health Model

FBA FBA 1 FBA

marital status -

FBA time since immigration

country of birth 1 FBA - pp -- - -

hig hest education attained

FBA

main activity caring for family

A 1 FBA

househoid incorne adequacy

FBA FBA

worù status

restriction of activity

FBA FBA

I

F=included in forward selection (SLE=0.25) B=included in backward selection (SLS=0.25) A= included in al1 sub-sets regression

- Table 17: Final Models for Self-Assessed Health. Disability Days and Mental Distress in 476 Immigrant Women Currently Working in Main ~cc@at&

-

Outcome

Self-Assessed Health

Disability Days

Mental Oistress

Independent Variables

-

Manual Job Age 30-49 Age 50-64 Immigrated 0-9 Years Ago Born in S.America/Africa Born in Asia Born in USNMexico Highschool Graduate Sorne Post-secondary College Diploma University Deg ree Care for Family Low lncome Adequacy Medium lncome Adequacy Restrictions of Activity

Age 30-39 Age 40-49 Age 50-64 Care for Family Low lncome Adequacy Medium lncome Adequacy Restrictions of Activity

Manual Job Age 30-39 Age 40-49 Age 50-64 lmmigrated 0-9 Years Ago Low lncome Adequacy Medium Incorne Adequacy Restn'ctio n of Act ivity

Odds Ratiosi Parameter Estimate (95% CI)

2.0(0.7,5.6) 0.9(0.3,3.0) 1.7(0.4,6.3) 0.4(0.1,3.7) 2.5(0.8,7.9) 3.8(1.4,10.4) 2.0(0.6,7.0) O.4(O. 1 -1.4) 0.2(0.1,0.8) 0.3(0.1,1.2) 0.2(0.1,1 .O) 2.2(1.0,5.0) 0.3(0.1,1.2) O.s(O.2,1.3) 9.1 (3.7,22.4)

1.5(0.7,3.4) 2.1 (0.9,4.7) O.8(0.3,Z.I ) 1.3(0.8,2.2) 1.8(0.9,3.7) O.?(O.4,1.4) 2.4(1.2,4.8)

O.?(-0.1,1.6) -1.1 (-2.0,-0.3) -1.1 (-2.1 ,-0.3) -1.9(-2.9,-1 .O) -0.9(-2.2.0.4) 1.3(0.4,2.2) 0.1 (-0.6,0.8) 0.6(-0.3,1.6)

- - -

Goodness of Fit ( Deviance, R2)

Table 18: Cornparison of Respondents Removed Due to Missing Information With those Retained in Study

Variable Category % in Women lncluded In Study

% in Women Excluded From Study

Fisher's 2-tailed P-value

Worù Status I Fu l l-t ime Part-time No Paid Work

Marital Status s Married Never Married Previously Married

No Yes

Restriction of 1 Activity No Yes

lncome Adequacy Lowest Low Middle High Highest DWNR

Time since Immigration

0-4 Years 5-9 Years 1 O+ Years DWNR

Country of Birth - - . . --

UsAlMexico S. AmericaIAfrica EuropefAustralia Asia DWNR

Education

Self-assessed Health

Disability Days

Less than Highschool Highschool Some Post- secondary College Diploma University Degree DWNR

Less than Good Good or Better

r 1 Disability Day No Disability Days

a 7 DISCUSSION -

7.1 MAlN FINDINGS

Paralleling several eariier studies on the association between wornen's health

and their work, this analysis found that associations in immigrant women Vary

depending on the specific health outcome examined. Nonetheless, at least for self-

assessed health, involvement in paid employment was associated with better health

among working-age immigrant women, dispelling the common belief that immigrant

women's roles as paid workers are not important to their health.

In the study of the 859 working-age immigrant women, only self-assessed health

was significantly associated with paid work. However, as others have shown for

women in general, the nature of the association differed according to whether women

were also involved in caring for their families. Thus, while paid work was protectively

associated with self-assessed health regardless of a woman's famil y care

responsibilities, the additional responsibility of caring for family diminished the strength

of this association. Paid workers who did not report caring for family declared fair or

poor self-assessed health five times less often than women who neither worked nor

cared for a family, while paid workers who cared for a family were only about two times

less likely to report the same. However, despite the finding that paid work is associated

with better self-assessed health, it should be noted that specific occupational hazards

were not examined in this study. Thus, while work appears to be protective, this does

not remove the well-established fact that many occupational hazards which can h a n

health are present in women's workplaces 1531.

By contrast with self-assessed health, neither disability days nor mental distress

was associated with paid work. This conflicts with several studies in the literature which

have found associations between work and disability days in the previous two weeks.

The lack of association in this study could be a result of several factors. First, the

sample size was much smaller than that of similar suweys on women in general. For

example, one analysis of the British General Household Survey studied more than

14,000 working-age women [13]. Large sample sizes permit both much smaller

associations to be detected with statistical significance and the examination of multiple

interactions. The magnitude of the non-significant associations found between work

status and disability days in this study were of the order O.R.=0.8 depending on a

woman's caregiving roles. A similar pattern of interaction to that found for self-

assessed health was observed for disability days, although non-significant; work alone

had the greatest protective association, and the combination of paid and unpaid work

caring for family the least protective association. However, the confidence intervals for

the disability days outcome indicate that the power to detect protective associations of

the magnitude found in this study was inadequate. Although the association found was

not very strong, studies examining variables in the social environment rarely exhibit

large measures of association, so an odds ratio of 0.8 may be of practicai importance.

The subanalysis of immigrant women cunently employed in their main

occupation also revealed interesting findings. As for male immigrants, the type of work

perforrned by immigrant women was associated with self-assessed health. Women in

manual occupations were at a disadvantage compared with those in other occupations.

even when potential wnfounden such as incorne, education, health selection out of the

work force and ethnicity were controlled (O.R.=2.0, 95% C.kO.7-5.6), suggesting that

characteristics of manual occupations, other than income earned may be associated

with poorer health. Any number of characteristics rnay be implicated, for example, lack

of unionization, low job control, little advancernent opportunity, low fiexibility or status.

When health selection was controlled, the negative association between rnanual work

and both poorer self-assessed health and higher mental distress actually increased.

This rnay be due to higher levels of fitness required to do these jobs, making it easier

for women to be selected out of this type of employment (491. This suggests that there

is greater selection out of manual occupations than non-manual, a finding supported in

the literature. Therefore, there is evidence that immigrant wornen working in manual

jobs experience poorer health than their non-rnanual counterparts and that they are

more likely to be selected out of employrnent due to poor health than their non-manual

counterparts. If such selection occurs, former employment in manual work may be

associated with poorer health in immigrant women who are no longer employed.

Several other studies have shown such a pattern. Studies on women in general have

indicated that previous occupation can have an impact on health rnany years after

leaving the labour market, while studies of immigrants have suggested their poor health

in old age rnay be related to poor work conditions earlier in life. This inference could

not be tested here because former employment was not measured in the NPHS.

Women who had not been working in the previous year did not generally have their

main job coded.

Manual work was also associated with increased levels of mental distress.

However, as for self-assessed health, the association was not significant at the p=0.05

level (P=0.7,95% C.I.=-0.1 , 1.6). The association was confounded by income

adequacy, and once that was controlled. the association was weakened to the extent

that it was no longer significant. Thus, the poorer economic circumstances of manual

workers may account for some of the distress they experience. Nonetheless. a lack of

statistical significance based on the arbitrary cut-off of p=0.05 should not be taken as

evidence that manual work is not associated with health after income is controlled. The

size of the parameter estimate indicates that there still may be some cause for concem,

and the lack of statistical power to obtain a precise estimate should not dismiss this

finding .

By contrast, disability days in the previous Wo weeks were not associated with

working in manual occupations in either the simple or the multiple logistic regressions.

Regardless of which covariates were controlled, disability days retained an odds ratio

estimate of approximately 1 .O.

7.2 SECONDARY FINDINGS

Although not the primary aim of this study, the multivariate analyses also

pemitted examination of the independent associations of the covariates with the health

outcornes examined.

As observed by other researchers [75,76], ethnicity, as measured by country of

birVi, was independently associated with self-assessed health, with a magnitude equal

to, or even greater than, that associated with working in rnanual occupations. The

association with country of birth was also evident in the main analysis that combined

women in paid and unpaid work. Being bom in Asia, South America or Africa was

associated with poorer health in working-age women in general, though the association

with poorer health in women in the paid labour force was even stronger. This

association was independent of occupational status, and it did not confound the

association between occupation and health. As immigrants who are members of ethnic

minorities have been described as occupying a marginalized position in the labour

market-both those in the professions [63] and those in lower status occupations [5, 7,

301- the poorer health associated with being born in these countries may reflect the

health effects of such marginalization.

Additional socioewnomic status indicators were independently associated with

health. Depending on the health outcorne being examined, either higher income

adequacy or higher educational attainment was associated with better health. Carhg

for family, whether or not it was cornbined with paid work, was protectively associated

with self-assessed health. Being a medium-term immigrant was also associated with

significantly better self-assessed health, but interestingly, time since immigration was

not linearly associated with the health outcornes exarnined, a finding consistent with

studies that have shown an initial reduction in health on immigration associated with the

stress of the immigration and resettlement experience [8].

7.3 LIMITATIONS OF STUDY AND SUGGESTIONS FOR FUTURE RESEARCH

Study Design

The design of this study was cross-sectional. Cross-sectional designs do not

permit evaluation of the temporal sequence of the exposure-disease relationship.

Therefore, this study could not distinguish if paid work protected immigrant women from

poor health, or if wornen participated in paid work because they were healthy. Similarly ,

for manual work, this study could not detemine if manual occupations caused women

to suffer from poorer self-assessed health, or if women with poorer self-assessed health

were selected into manual work,

A stratification variable, restrictions of activity, acted as a crude control for

selection processes occurring in the labour market. However, the utility of restrictions

of activity for the control of health selection must be questioned. Clearly, many women

who work still report restrictions of activity, so controlling for this factor may represent

an overantrol of selection. Women experiencing long-terni health effects from their

work will have such effects removed upon control of restrictions of activity, and only

diflerences in a woman's curent health state will be evident. Controlling for restrictions

of activity in the main analysis of women of working age reduced the protective

association of paid work, but did not alter the direction of any associations. If using

restrictions of activity overcontrols for health selection, paid work may appear more

protective than it actually is.

A further difficulty with the use of restrictions of activity is the possibility that

different groups of immigrants report limiting long-standing illness differently. Sorne

e studies have found differences between native-born and certain immigrant groups in

the reporting of this variable [84].

The cross-sectional design of this study not only makes the temporal sequence

of the relationship between work status, occupational status and health uncertain, but

questions of causal direction also occur with other variables considered. For example,

differences in health associated with time since immigration may result from a shift in

source countries or from real duration effects, while differences associated with age

may be due to real age effects, or a cohort effect. Longitudinal studies are required to

distinguish from among these possibilities.

The use of previously collected data created limitations in this study. Sample

size constraints occurred as further recruitment of immigrant women was not possible.

lnsufficient sample size is a general problem in immigrant studies, particulariy those

relying on random samples of the population. Sample size constraints forced the

collapsing of categories, reduced the power to detect differences and hampered the

investigation of the health experiences of numerically small immigrant groups. However,

in cross-sectional studies, certain remedies are possible. Future studies rnay combine

results from several surveys as others have done (131. By combining several years of

data, a large enough sample is obtained to provide reliable estimates of health for

smaller subgroups of the population.

Relying on govemment surveys (usually for cost reasons) to obtain information

on the health of the immigrant population is also problematic. Govemment surveys

commonly aim to obtain representative samples of the general population, a goal that

may preclude the study of immigrant groups at most nsk for health problems. For

example, while recent immigrants make up only a small portion of the total population,

they are at special risk for adverse mental health and having unmet health care needs.

Unfortunately, representative samples of the general population will yield few recent

immigrants for analysis.

Future studies on immigrant women may also consider the problems of non-

response encountered in this study. Although partial non-response was not differential

with respect to both exposure and outcorne, the criterion required for bias to be present,

it did reveal how certain groups of immigrants may be under-represented in health

surveys. Under-representation can add to sample size dificulties and prevent the

precise estimation of associations. Special consideration should be given to the higher

partial non-response levels observed in this study in recent immigrants, those with

lower income adequacy and education or those not in paid employment. Furthermore,

survey non-response rates should be evaluated specifically for immigrants.

Conceptual bifficulties

Conceptual difficulties with this study are largely related to the use of previously

collected data provided by Statistics Canada. Since the questions asked in the survey

were predetemined, the choice of variables for analysis was restncted and several

areas that may have been of relevance were absent.

With respect to defining women as immigrants, several relevant factors could not

be examined. For example. knowing under which category women immigrated, their

age at migration. and the circumstances of their migration would have been desirable.

These factors may influence an immigrant woman's work status, occupation, and her

health. Broadly grouping immigrants together by "country of birth" makes questionable

any inference regarding cultural differences. Much cultural variation occurs even within

a single country; the collapsing of diverse countries together into four broad groups, as

was done by the NPHS, ignores such variation. Fortunately, the groupings prevented a

cultural deterministic interpretation of the results, pemitting a mdimentary evaluation of

the possible role of marginalization or racism in the health of immigrant women.

A more detailed evaluation of work status would have been of interest to allow a

finer breakdown of women not in paid employment into groups such as the unemployed

or those working in the hidden economy. For example, domestic workers confined to

individual households have been described as an 'invisible" work force at risk of being

exploited [23]. A breakdown of work status by the number of hours worked per week

rather than a crude division of kill-time/ part-time would also have been of interest.

Occupational class was also cnidely measured as manuallnon-manual. Sample size

constraints prevented a finer breakdown, but even the ability to class women into

detailed occupational groups would not have identified many problems from which

immigrant women in the work force are said to suffer. Lack of unionization, minimum

wage legislation, or benefits, and poor working conditions, are not captured in census

occupational groupings. Unfortunately data on specific occupational hazards or job

benefits were not available in the NPHS, preventing this type of analysis.

Even given a choice of variables, it is questionable whether quantitative

epidemiological approaches are the best method to study something as cornplex as

how immigrant women's labciur force activities are associated with health. As

discussed in the literature review, immigrant status, ethnicity, and time since

immigration are far-from-simple concepts in themselves, and the reductionist variables

available for analysis in epidemiologic studies may not adequately capture their

meanings [40]. Complicating matters further is the absence, in epidemiology, of

theoretical models of work-health relationships other than those studying occupational

hazards in association with health through specific biological mechanisms. As reported

in the literature review, some authors maintain that incorporating models of social roles,

such as role strain or role enhancement theories with those that examine structural

position or class is necessary. However, occupational class does not only measure

structural position. Often, specific or general occupational hazards and benefits are

also being captured. From these multiple factors, identifying the biological hazards, job

conditions, social roles and structural positions that lead to positive or negative health

consequences is dificult, and doing so within the framework of the migration

experience is even more challenging. Qualitative research rnay facilitate theory

developrnent [58] using specific techniques such as "theoretical" sampling where

inforrnants are sarnpled iteratively with the objective of developing and refining a theory

[52]. The curent lack of a coherent theory suggests that qualitative descriptions are

potentially more useful than quantitative research based on underdeveloped theories.

If epidemiology is to contribute to further understanding of immigrant women's health,

promoting a dialogue with oaier disciplines appears essential.

Validity Issues

The data used in this study were based on self-reports, and it is well established

that the reporting of health problems may be affected by cultural factors, particularly for

mental health measures. The health outcomes examined in this study were not

validated separately for the immigrant population. Some researchers have suggested

that detailed qualitative assessment is necessary before quantitative assessment of

psychological health is done [89]. Thus, there is a need to validate these outcome

rneasures, though this may be difficult as they measure rather abstract concepts.

Validation of abstract measures of health has been said to be an ongoing process [74].

The constnict validity of self-assessed health has been examined in several studies, as

has its association with mortality in the general population. However, it has not

undergone similar validation specifically in the immigrant population. Nonetheless, self-

assessments of health are valid in the sense that they represent the respondent's

subjective feelings about her health.

Further problems with the validity of the self-reported data in this study stem from

the use of translated materials. Translation is not an exact science; the cultural context

associated with apparently similar words inevitably differs in subtle respects. It is not

known whether the questions used in the NPHS had been previously piloted. so

assuming the questionnaires to be prone to translation problems would be prudent.

7.4 STRENGTHS OF STUDY

One strength of this study was its attention to the interaction between women's

paid and unpaid work. Studies considering the associations between work and health.

partieulady among immigrants, have not considered the gendered nature of such

associations, and at most have controlled for sex in the analysis without considering

that women often have a dual workload. This is not surprising considering that

women's unwaged work has not been officially recognized until recently [90]. For the

first tirne, the 1996 Canadian Census requested information on household activities,

including the time spent weekly on unpaid housework, looking after children without

pay, and providing unpaid care or assistance to the elderly, to understand better how

unpaid activities contribute to the well-being of Canadians [67l. This information should

be helpful in understanding the degree and nature of women's unpaid household work,

an essential step towards understanding the interaction between women's paid and

unpaid work in the association with health.

Previous studies that have considered how women's domestic and paid labour

interact to affect the association with health have often measured the presence of

dependent children. Such studies have yielded inconsistent findings. This study used a

different measure of unpaid domestic work; a woman's own assessrnent that one of her

main activities involved caring for family. Since this measure was based on a woman's

self-perception of her main activities it may be a more suitable rneasure of her domestic

workload. The presence of dependent children as a measure of household labour,

although seerningly objective and relia ble, only indiredy measures a woman's

domestic work. and, as revealed by some cross-tabulations in this study, not al1 women

with dependent children feel that their main acüvw is carhg for them. white other

women without dependent children perceive their main activities as caring for family.

Another strength of this study is its specific focus on immigrant women, a

practice in accordance with suggestions that the diversity within ethnic grou ps be

attended to [44]. Many studies that consider immigrants do so for the purpose of

comparing their health with that of the native-bom population. This practice ignores

that the immigrant population, in itself, is complex and shows much variability.

Furthemore, such comparisons often do not consider that the immigrant population is

selected for health and other factors, for example economic ones, shown to contribute

to health. Finally. such comparisons ignore that immigrants and native-bom individuals

have very different experiences due to the marginal position occupied by many

immigrants in Canadian society, and comparing the two based on simple dichotomies

disregards differences in experience. For example, living and working conditions, as

well as cultural practices affect health in negative or positive directions. By

concentrating on immigrant women alone, this study avoided the issue of lack of

comparability of immigrant and native-bom individuals and addressed some of the

diversity among immigrant women.

7.5 SUMMARY

Despite the limitations of this study, finding that manual workers report poorer

health than non-rnanual workets and women not in paid employment report poorer

health than women working full or part-üme suggests that more attention needs to be

focussed on the health needs of these groups. Furthemore, finding differences in

immigrant women's health depending on domestic responsibilities, the type of paid work

involved, and the dimension of health measured reveals that heterogeneity in this

population must be considered.

This study provides an example that interpreting epidemiologic studies of this

cumplex population should proceed with caution. While this study found an interaction

hypothesized to occur a prion, others have suggested that many interacting factors

likely occur, so that understanding the health of the immigrant population through

epidemiologic studies may be impossible. Epidemiologic studies, which rely on

assigning people to categories, and controlling for extraneous variables are limited.

Controlling for confounders may not be as important as examining the cumplex

interactions between various factors whicti contribute to health. Careful attention should

be given to studies from other disciplines that consider the complex role of setting and

the uniqueness of experience when examining immigrant health, rather than reducing

the complexity of this population to make generalizations about immigrant women either

as a whole or based on broad categories required for epidemiological evaluations.

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Weighted results were attained by rescaling the individual weights so that they average to one, which accounts for unequal probabilities of selection.

Table W8a: Weighted Final Model for Association Between Work and Self-Assessed Health in Immigrant Women

Model

Paid Work Caregiver Paid Work'Caregiver lmmigrated 0-4 Years Ag0 lmmigrated 5-9 Years Ag0 Asia S.ArnericaîAfrica USNMexico Hig hschool Graduate Some Post-secondary College Diploma University Degree Restriction of Activity

Paramete r Estimate

Odds Ratio

Deviance x2

Table W9: Weighted Final Model for Association Between Work and Disability days in Immigrant Women

Parameter Odds Ratio 95% C.I. Deviance 1 Estirnate 1 1 1 X? ( paid work -0.09 low income adequacy

Table W10: Weighted Final Model for Association Between Work and Mental Distress in Immigrant Women

Model

paid work age 30-39 age 40-49 age 50-64 low income adequacy medium income adequacy never married previously married restrictions of activity

Parameter Estimate

Table W17: Final Models for Self-Assessed Health, Disability Days and Mental Distress Outcornes for 476 Immigrant Women Cunently Working in Main occupation

Outcome

Self-Assessed Health

Disability Days

Mental Distress

lndependent Variables

-- pp - - - -

Manual Job Age 30-49 Age 50-64 lmmigrated 0-9 Years Ago Born in S.America/Africa Born in Asia Born in U.S.A.1Mexico Highschool Graduate Some Post-secondary College Diplorna University Degree Care for Family Low lncome Adequacy Medium lncome Adequacy Restrictions of Activity

Age 30-39 Age 40-49 Age 50-64 Cam for Family Low lncome Adequacy Medium lncome Adequacy Restrictions of Activity

Manuai Job Age 30-39 Age 40-49 Age 50-64 lmrnigrated 0-9 Yean Ago Low lncome Adequacy Medium Incorne Adequacy Restriction of Activity

Odds Ratio1 Parameter Estimate (95% CI)

Goodness of Fit

( Deviance, R2)

IMMIGRANT STATUSIETHNICIN:

SOCIO-QI : In what country were you bom? (Do not read list. Mark one only.)

- Canada (Go to next section) - Jamaica - China - Netheriands - France - Philippines - Germany - Poland - Greece - Portugal - Guyana - United Kingdom - Hong Kong - United States - Hungary - Viet Nam - India - Other (Specify ) - ltal y DK, R (Go to SOCIO-Q4)

TlME SlNCE IMMIGRATION:

SOCIO-Q3: In what year did you first immigrate to Canada? - Year (4digits) (Enter < 1 999>if Canadian citizen by birth)

AGE

What is your date of birth? DDIMMM (Age is calculated and confirmed with respondent)

MARITAL STATUS

DEMO-QG: What is your cuvent marital status? (Note: if age < 15, marital status is automatically=single)

- Now married - Common-faw - Living with a partner - Single (never rnamed) - Widowed - Separated - Divorced

a RESTRICTION OF ACTIVITES -

RESTR-CINT: If age42, go to next section.

RESTR-INT: The next few questions deal with any health limitations which affect your daily activities. In these questions, "long-term conditions" refer to conditions that have lasted or are expected to last at least six months or more.

RESTR-QI : Because of a long-term physical or mental condition or health problem, are you limited in the kind or amount of activity you can do:

a) at home? - Yes - No - R (Go to next section)

b) at school? - Yes - No - Not applicable

R (Go to next section)

C) at work? - Yes - No - Not applicable

R (Go to next section)

D) in other activities such as transportation to or from work or leisure time activities? - Yes - No - R (Go to next section)

RESTR-Q2: Do you have any long-term disabilities or handicaps? - Yes - No - R (Go to next sedion)

- EDUC-CI : If age42, go to next section.

EDUC-QI : Excluding kindergarten, how many years of elementary and high school have you successfully completed?

(Do not read list. Mark one only.) - No schooling (Go to next section) - One to five years - Ten - Six - Eteven - Seven - Twelve - Eight - Thirteen - Nine DK, R (Go to next

section) (If age < 15 then go to next section)

Have you graduated from highschool? - Yes - No

Have you ever attended any other kind of school such as university, community college, business school, trade or vocational school, CEGEP, or other post-secondary institution?

- Yes - NO (GO to EDUC-CS) - DK, R (Go to next section)

What is the highest level of education that you have attained? (Do not read list. Mark one only) - some trade, technical, vocational school or business college - some community college, CEGEP, or nursing school - some university - diploma or certificate from trade, technical or vocational school

or business cdlege - diploma or cetiificate from comrnunity college, CEGEP, or

nursing school - Bachelor's or undergraduate degree or teacher's college (e.g.

BA, Mc., LL.B.) - Master's (M.A., M.Sc., Med) - degree in medicine, dentistry, veterinary medicine or

optometry (MD, DOS, D.M.D., D.V.M., OD) - eamed doctorate (e.g. Ph.D., M c , M d ) - other ( S p e c d y )

a INCOME ADEQUACY:

INCOM-Q3: What is your best estimate of the total incorne before taxes and deductions of al1 household memben from al! sources in the past 12 months? Was the total household income:

- Less than $20.000? - Less than $1 0,000? - Less than $5,000? - $5,000 and more?

- $10,000 and more? - Less than $15,000? - $15,000 and more?

- $20,000 and more? - Less than $40,0007

Less than $30,000? - $30,000 and more?

- $40,000 and more? - Less than $50,0007 - $50,000 to less than $60,000? - $60,000 to less than $80,0001 - $80,000 and more?

- No incorne DK, R (Go to next section)

(Go to next section) (Go to next section)

(Go to next section) (Go to next section)

(Go to next section) (Go to next section)

(Go to next section) (Go to next section) (Go to next section) (Go to next section)

CAREGIVER STATUS:

LFS-QI : What do you consider to be your current main activity? (For example, working for pay, caring for family.)

- Canng for family - Working for pay or profit - Caring for family and working for pay or profit - Going to school - Recovering from ilInesdon disability - Looking for work - Retired - Other (Specify)

WORK STATUS:

LFS-12: The nest section contains questions about jobs or employment which you have had during the past 12 months. Please include such employment as part-time

jobs, contract work, baby sitting and any other paid work.

LFS-Q2: Have you worked for pay or profit at any time in the past 12 months? - Yes (Go to LFS-Q3.1) - No - DK, R (Go to next section)

Note: Questions LFS-Q3 to LFS-QI 1 are done as a roster allowing up to 6 job entered.

LFS-Q3.n: For whom else have you worked for pay or profit in the past 12 months? - (50 chars)

LFSQ4.n: Did you have that job 1 year ago, that is. on %12MOSAGO% without a break in employment since then?

- Yes (Go to LFS46.n) - No

DK. R (Go to next section)

LFS-Q5.n: Ehen did you start working at this job or business? MMIDDNY DK,R (Go to next section)

LFS46.n: Do you now have that job? - Yes (Go to LFS-Q8.n) - No - DK, R (Go to next section)

LFSQ7.n: When did you stop working at this job or business? MMIDDM DK, R (Go to next section)

LFSQ8.n: About how many hours per week do you usually work at this job? -- HOURS

LFS-Ql 1 .n: Did you do any other work for pay or profit in the past 12 months? - Yes - No - DK. R (GO to LFS-Q 12)

a OCCUPATION: -

LFS-Q12: Which was the main job? (Answer will be chosen from roster of jobs.) (Definition of main job will be supplied in the interviewers manual)

LFS-QI 3: Thinking about this main job, what kind of business, service or industry is this? (For example, wheat farm, trapping. road maintenance, retail shoe store, secondaty school)

(50 chars)

LFS-Q14: Again, thinking about this main job, what kind of work were you doing? (For example, medical lab technician, accounting clerk, secondary school teacher, supervisor of data entry unit, food processing labourer.)

(50 chars)

LFS-QI 5: In this work, what were your most important duties or activities? (For example, analysis of blood samples, verifying invoices, teaching rnathematics, arganizing work schedules, cleaning vegetables.)

(50 chars)

SELF-ASSESSED HEALTH: HO6-INT: This part of the survey deals with vanous aspects of your health. l'II be

asking about such things as physical activity, social relationships, health status and stress. By health, we mean not only the absence of disease or injury but also physical, mental and social well-being. l'II start with a few

questions conceming you health in general.

GENHLT-QI : In general, would you Say your health is: (Read k t . Mark one only.)

- Excellent? - Very good? - Good? - Fair? - Poor?

a DISABILITV DAYS: -

TWOWK-INT: The first few questions ask about your health during the past 14 days.

WOWK-QI : It is important for you to refer to the 14-day period from %2WKSAGO% to %YESTERDAY%. During that period, did you stay in bed at al1 because of illness or injury including any nights spent as a patient in a hospital?

- Yes - NO (GO to TWOWK-Q3) - DK, R (GO to TWOWK-Q5)

NVOWK-Q2: How many days did you stay in bed for al1 or most of the day?

- Days (Enter <O> if less than a day) ( I f44 days go to TWOWK-Q5) DK, R (Go to NVOWK-Q5)

TWOWK-Q3: (Not counting days spent in bed) During those 14 days, were there any days that you cut down on things you nomally do because of illness or injury?

NVOWK-Q4: How many days did you cut down on things for al1 or most of the day?

- Days (Enter <O> if less than a day)

MENTAL DISTRESS:

MHLTH-INTa: Now some questions about mental and ernotional well-being. During the past month, about how often did you feel:

... so sad that nothing could cheer you up? (Read list. Mark one on1 y.)

- All of the time - Most of the tirne - Some of the time - A little of the time - None of the time

DK, R (GO to MHLTH-Ql k)

... Newous? (Read list. Mark one only.) - All of the time - Most of the time - Some of the time - A little of the time - None of the time

DK, R (GO to MHLTH-QI k)

... Restless or fidgety? (Read list. Mark one only.)

y All of the time - Most of the time - Some of the time - A little of the time - None of the time

DK, R (GO to MHLTH-QI k

. . . Hopeless? (Read list. Mark one only.) - All of the tirne - Most of the time - Same of the time - A littfe of the time - None of the time

DK, R (GO to MHLTH-Ql k

.. . Worthless? (Read list. Mark one only.) - All of the time - Most of the time - Some of the time - A little of the time - None of the time

DK, R (GO to MHLTH-QI k

... That everything was an effort? (Read list. Mark one only.) - All of the time - Most of the tim8 - Some of the time - A little of the time - None of the thne

Variable - - --

Self-assessed Health (DVGH 194)

Mental Distress (DVMHDS94)

Disability Days (DVDSDY94)

Derived Variable For Working Status (DWVK94)

Derived Working Houn Pattern Based on All Jobs Reported (DWVH94)

Main Job Working Hours (DVMNWH94)

Main Job Work Duration (DVMNWD94)

Derived Variable For Working Hours For The First Job (DVWH 1 94)

Coding Information - -- - - - - - -

O=poor 1 =fair 2=good 3=very good 4=excellent

O(best)-24(worst) 99=not stated

0=0 days-14=14 days 99=not stated

1 =currently working 2=not currently working-but had job 3=did not work during last 12 months 6=not applicable 9=not stated

1 =1 job full-time 2=1 job part-time 3=only full-time at all jobs 4=only part-time at al1 jobs 5=some full-tirne, some part-tirne 6=not applicable 9=not stated

1 =full-time (30 hours or more) 2=part-time (less than 30 hours) 6=not applicable 9=not stated

O=Omonths-l2=12 months 96=not applicable 99=not stated

1 =full-time (30 hours or more) Z=part-time (less than 30 houn) 6=not applicable 9=not stated

Derived Variable For Work Duration of First JO b(DWVD194)

Derived Variable For Working Hours For The Second Job (DVWH294)

Derived Variable For Work Duration of Second Job (DWVD294)

- - ---

Derived Variable For Working Hours For The Third Job (DWVH394)

Derived Variable For Work Duration of Third Job (DWVD394)

Derived Pineo Socio-economic Classification of Occupations For Main Job(DVPIN94)

O=Omonths-124 2 months 96=not applicable 99=not stated

1 =full-time (30 hours or more) P=part-üme (less than 30 hours) 6=not applicable 9=not stated

O=Omonths-124 2 months 96=not applicable 99=not stated - --

1 =full-tirne (30 hours or more) 2=part-time (less than 30 houe) 6=not applicable 9=not stated

O=Omonths-12=12 months 96=not applicable 99=not stated

1 =self-employed professional P=employed professional 3=high level management 4=semi-professionals 5=technicians 6=middle management 7=supervisors 8=foremen and forewomen 9=s killed clerical/sales/service 1 O=skilled crafts and trades 1 1 =famers 1 2=semi-skilled clerical/sales 13=semi-skilled rnanual 1 4=uns killed clericaVsales/service 15=unskilled rnanual 1 6=farrn la bourers 96=not applicable 99=not stated

Grouped Age Cohorts (AGEGRPMM)

3 =20-24 yean 4 =25-29 years 5 =30-34 years 6 =35-39 years 7 =40-44 years 8 =45-49 years 9 =50-54 yean 10=55-59 years 1 1 =60-64 yean

Marital Status (MARSTATG)

Restriction of Activity (RES-FLG)

lncome Adequacy (DVI NC594)

Highest Level Of Education (DVEDC294)

rime Since Immigration :DVIMMIG)

1 =married/common-lawlpartner 2=single 3=other(widowedldivorcedlseparated) 9=not stated

1 =lowest income 2=lower middle income 3=middle income 4=upper middle income 5=hig hest income 9=not stated

1 =no schooling 2 =elementary school 3 =some secondary school 4 =secondary school graduation 5 =other beyond hig hschool 6 =some trade school etc. 7 =some community college 8 =some univenity 9 =diploma/certificate trade school 1 O=diplomalcertificate corn. coll.,CEGEP 1 1 =bachelor degree (includes LLB) 1 2=Master/Deg. in med icineidoctorate 99=not stated

1 =O to 4 years 215 to 9 years 3 4 0 years or more Q=not stated

Country of Birth (DVBORNG)

Derived Type of Household (DVHHTP94)

Persons in Household s 5 Years(NUMLE5G)

- - --

Persans in Household 6-1 1 Years (NUMGTII G)

Family Arrangements of Respondent (DVLVNG94)

Current Main Activity (LFS-QI )

2=United States and Mexico 3=Sout h AmericdAfrica 4=Eu rope/Au stralia 6=Asia 99=not stated

- -- - -

1 =couple with children ~ 2 5 2=couple with childrenz=25 &/or relatives 3=single 4=single with others 5=couple with children <25 and relatives 6=cou ple alone 7=single parent with children ~ 2 5 only 8=other single parent household 9=other 99=not stated

1 =unattached individual living alone 2=unattached individual living with others 3=spouse/partner living wt spouselpartner 4=parent living wt spouselpartner & child 5=single parent living wt children only 6=child living wt single parent(no foster) 7=child living wt single parent 8 siblings 8=child living with h o parents 9=child living with h o parents & siblings 1 O=other 99=not stated

- - - - --

1 =carhg for family 2=working for pay or profit 3worWcaring for family for paylprofit 4-going to school S=recovering from illnesslon disability 6=looking for work 7=retired 8=other 96=not applicable 99=not sbted

&Dendix 4 s d a b b ~

lncome adequacy is based on information gathered on household income and household size.

Category lncome Lowest lncome <$10,000

<$15.000 Lower Middle Income $1 0.000-$14,999

$1 0,000-$19,999 $1 5,OOO-$2629,999

Middle Income $1 5,000$29,999 $20,000-$39,999 $30,000-$59,999

U pper Middle l ncorne $30,000-$59,999 $40,000-$79,999 $60,000-$79,999

Highest lncome 2$60,000 r $8O,OOO

Unknown Not Stated

Household Size 1-4 persons 5 or more persons 1 or 2 persons 3 or 4 persons 5 or more persons 1 or 2 persons 3 or 4 persons 5 or more persons 1 or 2 persons 3 or 4 persons 5 or more persons 1 or 2 persons 3 persons or more Not applicable

Va ria ble

Self-Assessed Health (DVG H 194)

Disability Days (DVDSDY94)

Occupation (DVPI N94)

Age (AGEGRPMM)

(LFS-Q1 ) 1 Do not Care for Family 1 2,4-8

Groupings in Study

Poor Good or Better

One or More None

Incorne Adequacy (DVI NC594)

Educational Attainment (DVEDC294)

Current Main Activity

see Appendix 3 for categories associated with codes

Codes in NPHSg

0. 1 2-4

1-14 O

Manual Non-Manua!

20-29 30-39 40-49 50-64

10,13,15,16 1-9,11.12.14

3,4 5.6 7t8 9-1 1

Low Medium High

Less than Highschool Highschool Some Post-secondary College Diploma University Oeg ree

Care for Family

1 2 3 43.9

1-3 4 5-8 9,lO 11,12

1.3

AP- 7: -r far be- W Q r b u m u w m h œ œ

a Table A l : Full Model lncluding Interaction Tem for Association Between Paid Work and Self-Assessed ~ea l t h

Variable

- -

paid work ca reg iver paid work'caregiver age 30-39 age 40-49 age 50-64 immigrated 0-4 years ago immigrated 5-9 years ago born in Asia born in S.America/Africa bom in USAIMexico hig hschool graduation some post-secondary college diploma univers@ degree low income adequacy medium income adequacy never married previousl y married restrictions of activity

Parameter Estimate

-1.47 -1 .O1 1.73

-0.07 0.08 O .43 -0.07 -1.47 0.71 0.80

-0.23 -0.27 -0.69 -1 .O9 -0.79 0.08 0.1 9 -0.45 0 .O4 2.38

Odds Ratio (95% C.I.)

Wald x2 p-value

Table A 2 Odds Ratios and 95% C.I. for Association Behnreen Work and Health For Levels of Caregiver Status Based on Parameter Estimates from Full Model

I PaidWoh 1 NO Paid Work 1

Care for Family

Don? Care for Family

0.47 (0.22.0.99) 0.36 (0.1 8,0.73)

0.23 (O. 1 1,0.48) Reference

Table A3: Odds Ratios and 95% C.I. for Association Between Paid Work and Health for Levels of Caregiver Status Based on Parameter Estimates from Model Containing: paid work, caregiver, paid work'caregiver, time since immigration, country of birth, educational attainment, incorne adequacy. marital status, and restrictions of activity

1 Family 1 1 1

Care for Family

Don't Care for

Table A4: Odds Ratios and 95% C.1. for Association Between Paid Work and Health for Levels of Caregiver Status Based on Parameter Estimates from Model Containing: paid work. caregiver, paid work'caregiver, age, time since immigration, country of birth, educational attainment. marital status, and restrictions of activity

0.42 (0.20,0.86)

0.20 (0.1 0.0.42)

1 Care for (0.23.0.99) 0.37 (0.19.0.74) I

0.34 (0.1 7,Q.67)

Reference

Table A5: Odds Ratios and 95% C.I. for Association Between Paid Work and Health for Levels of Caregiver Status Based on Parameter Estimates from Model Containing: paid work, caregiver, paid work*caregiver, time since immigration, country of birth,

Don't Care for (0.1 1,0.47) Famil y

ed ucational attainment, and restrictions of activity

Reference

1 Paid Work 1 No Paid Work

1 Family 1 1

1 Cam for FarniIy 0.47 (0.24.0.92) - I O38 (020.0.72)

Table A6: Odds Ratios and 95% C.I. for Association Between Paid Work and Health for Levels of Caregiver Status Based on Parameter Estimates from Model Containing: paid work, caregiver, paid work'caregiver, age, time since immigration, country of birth, educational attainment, inwme adequacy, and restrictions of activity

I 1 Paid Work 1 No Paid Work I Care for Family

Table A7: Odds Ratios and 95% C.I. for Association Between Paid Work and Health for Levels of Caregiver Status Based on Parameter Estimates from Model Containing: paid work, caregiver, paid work'caregiver, time since immigration, educational attainment, incorne adequacy, marital status, and restrictions of activity

Don't Care for Farnily

Paid Worù

0.51 (0.25,1.04) 0.39 (0.20.0.76)

0.24 (0.1 1,0.49) 1

Reference

Care for Family

Table AS: Odds Ratios and 95% C.I. for Association Between Paid Work and Health for Levels of Caregiver Status Based on Parameter Estimates from Model containing: paid work, caregiver, paid work'caregiver, educational attainment and restrictions of activity

1 Don7 Care for 1 0.20 (O.lO.O.41) Famil y

1 Paid Woik

0.45 (0.22,0.88)

Reference

0.36 (0.1 9,O.67)

Care for Family

/ DonttCarefor )0.19(0.10.0.39) Family

0.46 (0.24.0.88)

Reference

0.33 (O. 18,O .62)

Table Ag: Odds Ratios and 95% C.I. for Association Between Paid Work and Health for Levels of Caregiver Status Based on Parameter Estimates from Model containing: paid work, caregiver, paid work'caregiver, time since immigration, educational attainment and restrictions of activity

Care for Farnily

Table A10: Odds Ratios and 95% C.I. for Association Between Paid Work and Health for Levels of Caregiver Status Based on Parameter Estimates from Model containing: paid work, caregiver, paid work*caregiver, and restrictions of activity

Don't Care for Family

1 Paid Worù

0.45 (0.23,0.88)

1 No Paid Work I

0.36 (0.1 9,O.68)

0.20 (0.1 O , O A ) Reference

1 Don't Cam for 1 0.19 (0.09,0.37) 1 Reference 1

Care for Family

1 Family 1 1 I

0.42 (0.22,0.79) 0.39 (0.21,0.70)

Table B i : Full Model Including Interaction Tenn for Association Between Paid Work and Self-Assessed Health

Variable

paid worù ca reg ive r paid work'caregiver age 30-39 age 40-49 age 50-64 immigrated 0-4 years ago immigrated 5-9 years ago bom in Asia bon in S.America/Africa born in USNMexico highschool graduation some post-secondary college diplorna university degree low income adequacy medium income adequacy never mamed previously married restrictions of activity

Parameter Estirnate

-0.40 -0.24 O -47 0.18 0.12 -0.12 -0.21 -0.34 -0.13 0.02 0.03 -0.43 -0.10 -0.32 -0.01 0.53 -0.28 -0.23 -0.37 1.25

Odds Ratio (95% CL)

Wald x2 p-value

Table 82: Odds Ratios and 95% C.I. for Association Between Paid Work and Disability Days For Levels of Caregiver Status Based on Parameter Estimates from Full Model

Care for Family

Don? tare for Famil y

0.84 (0.45.1.57) 0.79 (0.44.1.41 )

0.67 (O.38,t. 19) Reference

Table 83: Full Model (No Interactions) for Association Between Paid Work and DisabilityDayç

Variable

paid work careg iver age 3039 age 40-49 age 50-64 immigrated 0-4 years ago immigrated 5-9 years ago born in Asia born in S .America/Africa born in USAlMexico hig hschool graduation some post-secondary college diploma univenity degree low incorne adequacy medium inwme adequacy never married previously married restrictions of activity

Parameter Estimate

Odds Ratio (95% C.1 .)

0.87 (0.57, 1.30) 1 .O2 (0.68, 1.55) 1.20 (0.67, 2.17) 1.16 (0.62, 2.15) 0.92 (0.49, 1.73) 0.82 (0.43, 1.55) 0.70 (0.38, 1.30) 0.86 (0.51, 1.45) i .O3 (0.58, 1.82) 1 .O1 (0.55, 1.83) 0.66 (0.36, 1.21 ) 0.94 (0.54. 1.62) 0.75 (0.40, 1.40) 1 .O1 (0.54, 1.90) 1.71 (1 -03, 2.83) 0.76 (0.47, 1.23) 0.82 (0.44, 1.50) 0.69 (0.41, 1.18) 3.54 (2.30, 5.43)

Table 84: Reduced Model for Association Between Paid Work and Disability Days

paid work low income adequacy medium income adequacy restrictions of activity

Variable Parameter Estimate

Odds Ratio (95% C.I.)

Table C l : Full Model lncluding Interaction Term for Association Between Paid Work and Mental Distress

Variable

paid work careg iver paid worù'careg iver age 30-39 age 40-49 age 50-64 irnmigrated 0-4 years ago immigrated 5-9 years ago born in Asia born in S.America/Africa bon in UsAlMexico highschool graduation some post-secondary college diploma un iversity deg ree low income adequacy medium incorne adequacy never rnarried previously mamed restrictions of activity

Estimated Mean

Difference in Distress

-0.42 -0.61 0.58

-0.86 -0.93 -2.03 -0.61 -0.30 -0.18 -0.17 -0.48 -0.29 O .20 -0.65 -0.37 1.24 0.23 0.63 0.70 1.35

95% Confidence Interval

p-val ue

Table C2: Mean Difference in Distress and 95% C.I. for Association Between Paid Work and Mental Distress For Levels of Caregiver Status Based on Parameter Estimates from Full Model

I Paid Work 1 No Paid Work

1 Care for Farnily 1 -O.45(-1.30, 0.40) 1 -0.61 (-1.43, 0.21 ) 1 1 Don't Care for 1 -0.42 (-1 .19,0.34) Famil y

Reference

Table C3: Full Model (No Interaction) for Association Between Paid . Work and Mental Distress

Variable

paid work careg iver age 30-39 age 40-49 age 50-64 immigrated 0-4 years ago immigrated 5-9 years ago born in Asia bom in S.America/Africa bom in USA/Mexico highschool graduation some post-secondary college diploma university degree low income adequacy medium income adequacy never married previously married restrictions of activity

Estimated Mean Difference in Distress

95% Confidence Interval

-0.63,0.43 -0.78.0.28 -1.60, -0.1 2 -1.70, -0.14 -2.80, -1 -20 -1.38, 0.22 -1.07,0.45 -0.85,0.44 -0.91.0.57 -1 .29,0.27 -1.09,0.51 -O.53,O.99 -1.43, 0.21 -1.22, 0.50 0.56, 1.93 -0.35, 0.83 -0.1 2, 1.44 0.03, 1.40 0.73, 2.02

Table C4: Reduced Model (No Interaction) for Association Between Paid Paid Work and Mental Distress

Variable

paid work age 30-39 age 40-49 age 50-64 low inwme adequacy medium income adequacy never rnamed previously mamed restrictions of acüvity

Estimated Mean Difference in

Distress

95% Confidence Interval

Amendix 8: Conceatual Mode1 of Association Between Work Status. Occupational Status and Health State

Immigrant Status - - - \

*tirne since immigration \ \

4 \ \

I ---/-"' *country of birth \ -. / \

\

\ \

/

--------.----.------------œœ----------------------------w------------------------.--------.--------------

7. Adapted from [13] 1 46